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ANESTHESIA 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/anesthesiaOOgwat 


ANESTHESIA 


BY 


JAMES  TAYLOE  GWATHMEY,  M.D. 

FIRST   PRESIDENT    OF   AMERICAN  ASSOCIATION   OF   ANESTHETISTS,    ANESTHETIST   TO   THE   NEW    YORK   SKIN   AND 
CANCER,  ST.  VINCENT,  RED  CROSS  AND  COLCMBIA  HOSPITALS,  AND   ST.  BARTHOLOMEW'S  CLINIC,  MEMBER 
OF  AMERICAN  MEDICAL   ASSOCIATION   AND   THE   NEW    YORK   ACADEMY   OF  MEDICINE 


IN  COLLABORATION  WITH 

CHARLES  BASKERVILLE,  Ph.D.,  F.C.S. 

PROFESSOR   OF  CHEMISTRY   IN   THE  COLLEGE   OF  THE    CITY   OF   NEW   YORK,    MEMBER    AMERICAN    AND    GERMAN 

CHEMICAL   SOCIETIES,    ELECTRO-CHEMICAL   SOCIETY,    INSTITUTE    OF   CHEMICAL   ENGINEERS,   AMERICAN 

ASSOCIATION  OF  ANESTHETISTS,  NEW  YORK  AND  WASHINGTON  ACADEMIES  OF  SCIENCE,  ETC. 


WITH   TWO  HUNDRED  AND  EIGHTY-THREE 
ILLUSTRATIONS  IN  THE  TEXT 


NEW  YORK  AND  LONDON 

D.  APPLETON  AND   COMPANY 

1914 


COPTRIGHT,   1914,  BY 

D.  APPLETON   AND   COMPANY 


s^..M; 


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Printed  in  the  United  States  of  America 


* 


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'^Even  as  a  surgeon  minding  oft  to  cut 
Some  careless  limb,  before  in  use  he  puts 
His  violent  engines  in  the  victim's  member, 
Bringeth  his  patient  in  a  senseless  slumber; 
And  griefless  then,  guided  by  use  and  art, 
To  save  the  whole,  saws  off  the  infested  part." 

— DUBARTAS,  1592  A.  D. 


LIST  OF  CONTRIBUTORS 


WILLIAM    SEAMAN    BAINBRIDGE,    A.M.,    Sc.D.,    M.D. 
Professor  of  Surgery,  N.  Y,  Polyclinic  Medical  School  and  Hospital;  Sur- 
geon, N.  Y.  Skin  and  Cancer  Hospital;  Attending  Surgeon, 
N.  Y.  City  Children's  Hospitals  and  Schools;  Consult- 
ing Surgeon,  Manhattan  State  Hospital, 
Ward's  Island,  Etc. 

JOHN  W.   H.   CRIM,   L.L,  LL.B. 
Former  Assistant  United   States   Attorney;    Former   Special   Assistant   At- 
torney-General of  the  United  States. 

CHARLES  A.  ELSE  ERG,  A.B.,  M.D. 
Professor  of   Clinical   Surgery,   University   and  Bellevue   Hospital    Medical 
College,  New  York;  Attending  Surgeon,  Mount  Sinai  Hos- 
pital and  New  York  Neurological  Institute 

HORACE  W.  FRINK,  M.D. 

W.  D.  GATCH,  A.B.,  M.D. 

Professor  of  Surgery,  Indiana  University  School  of  Medicine, 

Indianapolis,  Ind. 

JAMES  F.  MITCHELL,  A.B.,  M.D. 
Surgeon  to  Providence  Hospital 

HERRMANN  PRINZ,  M.D.,  D.D.S. 

Professor  of  Dental  Materia  Medica,  Pharmacology  and  Therapeutics,  Thomas 

W.  Evans  Museum  and  Dental  Institute,  School  of  Dentistry, 

University  of  Pennsylvania,  Philadelphia 

LOUISE  G.  ROBINOVITCH,  B.esL.,  M.D.   (Paris) 
Member,    New    York    Academy    of    Medicine;    Member,    American    Medical 
Association;  Foreign  Associate  Member,  Medico- 
Psychological  Society,  Paris 

WALTER  S.  SUTTON,  A.B.,  A.M.,  M.D.,  F.A.C.S. 

Associate  Professor  of  Surgerj^,  University  of  Kansas  School  of  Medicine, 

Attending  Surgeon,  Bell  Memorial  Hospital, 

Kansas   City,   Mo. 

JAMES  J.  WALSH,  M.D.,  Ph.D.,  LL.D.,  K.  St.  G. 

Formerly  Dean   and  Professor  of  Nervous  Diseases,   Fordham   University 

School  of  Medicine,  New   York  City 


PREFACE 

The  administration  of  anesthetics,  along  with  practically  every  other 
phase  of  medicine  and  surgery,  is  undergoing  a  steady  evolution.  The 
development  in  the  application  of  anesthetics  has  been  most  marked 
within  recent  years,  so  that  any  given  anesthetic  or  method  which  is 
considered  the  best  to-day  may  be  entirely  replaced  by  a  safer  and  a  bet- 
ter to-morrow.  Even  to-day  there  is  not  a  little  divergence  of  opinion  as 
to  which  is  the  best  method.  No  longer  are  the  leaders-  in  medicine  and 
surgery  satisfied  with  a  form  of  anesthesia  which  simply  renders  the 
afflicted  one  insensible  to  pain  during  an  operation,  and  which  allows 
the  surgeon  to  work  with  great  freedom  and  confidence,  but  they  insist 
j^urther,  and  rightly,  upon  maintaining  the  patient's  vitality,  reducing 
the  effect  of  shock  as  much  as  possible,  and  having  the  patient  as  com- 
fortable as  may  be  during  recovery  and  convalescence. 

"Every  hospital,  certainly  every  large  hospital,  should  have  as  a  regu- 
lar member  of  its  staff  an  attending  anesthetist,  as  is  the  case  in  some, 
whose  authority  in  his  special  department  should  be  as  complete  as  is 
that  of  the  attending  physician  or  surgeon  in  their  fields.  This  arrange- 
ment will  be  particularly  important  during  the  next  few  years  when  the 
older  methods  of  anesthesia — chloroform,  ether,  cocain,  etc., — will  be  com- 
peting with,  and  greatly  modified  by,  newer  procedures,  e.  g.,  nitrous 
oxid,  intratracheal  insufflation,  spinal  anesthesia,  intravenous  anesthesia, 
intra-arterial  injection  of  novocain  by  the  methods  of  Bier  and  Eamshoff, 
measures  for  the  prevention  and  relief  of  acapnia,  the  prevention  of  pain 
associations,  etc."  * 

The  dignity  of  this  special  field  in  medicine  can  be  greatly  enhanced 
and  its  progress  equally  advanced  by  such  organizations  as  the  New  York 
and  American  Societies  of  Anesthetists,  wherein  the  theories  and  prac- 
tice are  fully  presented  and  discussed  with  the  liveliest  interest  and 
general  profit. 

*  From  the  Report  of  the  Committee  on  Anesthesia,  American  Medical  Associa- 
tion, June,  1912. 


X  PREFACE 

The  main  purposes  of  this  book  are : 

(1)  To  give  in  a  practical  and  utilizable  form  the  essentials  of  the 
subject  of  the  administration  of  anesthetics; 

(2)  To  save  the  busy  medical  practitioner  or  student  the  labor  of 
weeding  out  from  the  voluminous  literature  upon  the  subject  the  facts 
which  he  must  constantly  bear  in  mind  in  the  successful  practice  of  this 
important  branch  of  medicine ; 

(3)  To  emphasize,  wherever  possible,  the  thought  that  "to  bring  a 
living  being  to  that  borderland  in  which  life  in  many  respects  so  simu- 
lates death  should  at  no  time  be  a  fool's  occupation" ;  and 

(4)  While  primarily  intended  as  a  work  for  the  active  practitioner 
and  student,  to  suggest  many  lines  for  further  research. 

The  authors  will  be  grateful  for  suggestions,  and  especially  for  ac- 
counts of  unusual  experiences  met  with  in  practice. 

Due  consideration  has  been  given  to  the  historical  development  of 
anesthesia,  but  emphasis  has  been  laid  upon  modern  American  practice 
without  neglecting  European  procedures.  This  has  been  accomplished  by 
happily  securing  the  cooperation  of  successful  investigators — to  whom  sin- 
cere thanks  are  here  extended,  and  whose  names  appear  at  the  heads  of 
those  chapters  prepared  by  them — within  the  various  fields  of  the  sub- 
ject. Ample  space  has,  therefore,  been  given  to  methods  of  administra- 
tion which  are  as  yet  in  the  experimental  stage,  although  dominant  prom- 
inence has  gone  to  those  methods  whose  utility  has  become  established. 

A  list  of  anesthetics  with  valuable  data  and  references  (Chapter  XX) 
is  presented  complete,  as  far  as  we  are  aware,  for  the  first  time.  It  is 
hoped  that  the  contents  of  this  chapter  may  prove  of  value  not  only  to 
the  profession  of  medicine,  but  to  the  professions  of  dentistry,  pharmacy, 
and  chemistry  as  well,  for  there  the  investigator  may  possibly  find  a  drug 
more  nearly  ideal  for  his  purposes  than  any  now  in  general  use  for  ob- 
tunding  sensation  or  inducing  unconsciousness. 

As  modern  medicine  now  more  generally  recognizes  the  importance 
of  a  knowledge  of  chemistry  in  all  its  branches,  that  phase  of  the  sub- 
ject has  been  quite  fully  developed,  not  only  along  the  lines  of  original 
purity  of  the  drug  used,  the  conditions  favorable  to  its  preservation  in  its 
highest  purity,  but  its .  course  within  the  body,  resulting  either  in  the 
destruction  of  the  drug  or  its  elimination  from  the  body. 

To  some  it  might  have  been  desirable  to  indicate  from  whom  certain 
instruments  could  be  obtained  and  to  specify  the  quality  of  drugs  sup- 


PREFACE  xi 

plied  by  the  different  manufacturers,  but  for  obvious  reasons  that  could 
not  be.  As  for  the  latter,  the  absolute  purity  of  the  drug  administered 
cannot  be  too  strongly  emphasized.  The  standards  of  purity  given  in 
the  text  are  those  determined  after  prolonged  and  most  painstaking  in- 
vestigations. These  standards  of  purity  should  be  insisted  upon  by  the 
physician.  It  is  quite  out  of  the  question  to  have  every  sample  to  be  used 
examined  by  an  expert  chemist — and  only  an  expert  chemist  should  pass 
upon  the  quality  of  an  anesthetic — but  occasional  chemical  examinations 
may  be  made,  and,  knowing  the  quality  of  the  drug  as  supplied  on  the 
market,  one  must  then  place  reliance  upon  the  reputation  of  the  firm 
supplying  the  drug.  We  have  found  the  reputable  houses  anxious  to  pro- 
vide drugs  of  the  highest  purity,  but  unfortunately  close  chemical  super- 
vision does  not  always  obtain,  and  impure  products  do  get  upon  the  mar- 
ket through  carelessness  of  workmen  or  failure  to  provide  against  de- 
terioration of  the  drug,  even  though  it  leave  the  manufacturer  of  a  proper 
grade. 

James  Tayloe  Gwathmey. 

Charles  Baskerville. 
New  York  City. 


CONTENTS 

CHAPTER  I 

THE  HISTORY  OF  ANESTHESIA 

PAGE 

Introductory  Remarks  :  Ancient  Histoiy ;  Beginning-  of  the  Christian 
Era;  Asiatic  Sources;  Middle  Ages;  Hypnotism;  Real  Beginnings 
of  SurgicaL Anesthesia ;  Discovery  of  Ether  Anesthesia;  The  Dis- 
covery of  Nitrons  Oxid  for  Surgical  Anesthesia  ....       1-11 

Ether:     Morton;  Eirst  Public  Demonstration;  Letheon;  Anesthesia 

in   England 11-19 

Chloroform  :  Theological  Opposition  to  the  Use  of  Anesthetics ;  The 
Early  Use  of  Chloroform  in  Midwifery;  Some  Physicians  Believe 
in  Pain;  Prejudice  Developed  against  Chloroform;  Scientific  Ad- 
ministration of  Ether  and  Chloroform;  Efforts  to  Overcome  Ob- 
jections to  Chlorofoiin  by  Use  of  Substitutes  and  Improved  In- 
halers; A.C.E.  Mixture;  Substitutes;  First  Vapor  Inhaler; 
Nitrous  Oxid  More  Generally  Appreciated;  Nitrous  Oxid  and 
Oxygen;  Discarding  Chloroform  for  Ether;  Improved  Methods 
for  Administering  Ether;  Warmed  Ether  Vapor;  Chloroform 
Condemned;  Medication  before  Anesthesia;  The  Use  of  Chloro- 
form Accompanied  with  Danger;  Chloroform  and  Oxygen;  Com- 
binations and  Sequences  in  Anesthesia;  Ethyl  Chlorid;  Im- 
portance  of   Trained   Anesthetists 20-27 

Bibliography .        •        •    27-29 


CHAPTER  II 

general  physiology  of  inhalation  anesthesia 

Introductory  Remarks  :  Definition  of  Terms ;  Chief  Anesthetic  Agents     30-32 
Theories    of   the   Action    of    General    Anesthetics:    Spencer's 

Theory;    Binz's    Theory;    Bernard's    Theory;    Dubois'    Theoi-y; 

Schleich's    Theory;    Mliller's    Theory;    Meyer-Overton    Theory; 

Wright's    Theoi-y;    Traube's    Theoi-y;    Mathews-Brown    Theory; 

Moore-Roaf  Theory;  Gill's  Theory;  Hober's  Theory;  Baglioni's 

Theory;  Reicher's  Theory;  Gros's  Conclusions;  Biirker's  Theory; 

Verworn's  Theory;  Conclusions  of  Lillie;  Conclusions         .         .     32-56 


ij"- 


xiv  CONTENTS 

PAGE 

Effects  of  General  Anesthetics  upon  Various  Parts  of  the 
Organism:  The  Respiratory  System;  The  Circulatory  System; 
The  Muscular  System;  The  Glandular  System;  The  Nervous 
System 56-62 

Factors  Which  May  Be  Said  to  Modify  the  Physiology  of 
Anesthesia  as  Ordinarii;Y  Induced:  Warming  the  Agent; 
Experiments  on  Warming  Ether ;  Effects  of  Moisture ;  Combining 
Oxygen  with  the  Agent ;  The  Influence  upon  Anesthesia  of  Oxy- 
gen Intra-abdominally  Administered;  Preceding  the  Administra- 
tion with  Oil  of  Bitter  Orange  Peel;  Utilizing  Carbon  Dioxid     62-99 

CHAPTER  III 

THE  USE  OF  REBREATHING  IN  THE  ADMINISTRATION  OF  ANESTHETICS 

W.  B.  Gatch,  M.D. 

Ether:  Effect  of  Ether  Vapor  on  Respiratory  Passages;  Compari- 
son of  Toxic  Effects  Following  Use  of  Open  and  Closed  Methods ; 
Effects  of  Over-Concentration  of  Ether  Vapor  .  .  .  100-103 
ITROUS  OxiD,  Alone  and  Combined  with  Ether:  Method  of 
Administration;  Basis  of  Technique;  Practical  Advice;  Main- 
tenance of  Ether  Balance;  Elimination  of  Ether  from  the  Sys- 
tem; Effect  of  Morphin  on  Ether  Elimination;  Clinical  Results; 
Long  Operations;  Fatalities;  Cardiac  Cases;  Hypercapnia; 
Acapnia;  Ether  and  Acapnia;  Other  Advantages  of  Rebreathing; 
Post- Anesthetic  Nausea;  Post- Anesthetic  Abdominal  Distention; 
Post- Anesthetic  Lung  Complications;  Method  Demands  Experi- 
ence           103-115 

Chloroform  and  Ethyl  Chlorid:  Suggested  Investigations;  Dan- 
gers; Advantages 115-116 

CHAPTER   IV 

nitrous  oxid 

/ 

History:  Early  Use  in  Dentistry;  Nitrous  Oxid  Administered  with 
Oxygen;  Physical  Properties;  Chemical  Properties;  Impurities 
of  Nitrous  Oxid;  Standard  of  Purity 118-123 

Special  Physiology:  The  Hyper-Oxygenation  Theory;  The  Deoxy- 
genation  or  Asphyxiation  Theory;  The  Theory  of  the  Specific 
Action  of  Nitrous  Oxid  upon  the  Brain  Cells;  Effects  upon  the 
Respiratory  System ;  Effects  upon  the  Circulatory  System ;  Effects 
upon  the  Nervous  System;  Effects  upon  the  Muscular  System; 
Effects  upon  the  Glandular  System  and  Other  Structures ;  Causes 
of  Death;  Stages  of  Anesthesia;  Elimination;  After-effects         123-135 


CONTENTS  XV 

PAGB 

Comparison  with  Other  Agents 135 

Indications  and  Contraindications 135 

Administration  :  Heating-  the  Gas ;  Essential  Features  of  Any 
Satisfactory  Apparatus;  Apparatus  for  Administering  Nitrous 
Oxid  Alone  or  With  Air;  Dangers  of  Administration  of  Nitrous 
Oxid  Alone;  Recognition  of  Asphyxial  Symptoms;  Administra- 
tion of  Nitrous  Oxid  Alone ;  Administration  to  Asphyxiation  With 
and  Without  Valves;  Use  of  Expiratory  Valve  Alone;  Adminis- 
tration Without  Valves;  Precautions  When  Administered  Alone; 
Administration  of  Nitrous  Oxid  With  Air  in  Unknown  Quanti- 
ties; Administration  of  Nitrous  Oxid  With  Definite  Amounts 
of  Air;  Nitrous  Oxid  as  a  Sequence  to  Ether;  Nitrous  Oxid  With 
Air;  Technique  of  Ether-Nitrous  Oxid  (Air)  Sequences;  Tech- 
nique With  A.C.E. ;  Advantages  of  Ether  (or  Chlorof  orm-Ether) - 
Nitrous  Oxid  Sequence;  The  Advantages  of  Administration  of 
Nitrous  Oxid  With  Oxygen;  Superiority  of  Oxygen  Over  Air; 
The  Administration  of  Nitrous  Oxid  With  Indefinite  Quantities 
of  Oxygen;  Gatch's  Method  of  Administration;  Davis's  Method; 
Methods  of  Administration  with  Definite  Quantities  of  Nitrous 
Oxid  and  Oxygen;  Gwathmey's  Method;  Teter's  Method;  Tech- 
nique to  be  Followed  in  Administering  Nitrous  Oxid  and  Oxygen 
With  the  Teter  Apparatus  and  the  Teter  Nasal  Inhaler;  Nitrous 
Oxid  Oxygen  Endopharyngeally ;  Boothby  and  Cotton  Apparatus ; 
The  Gwathmey-Woolsey  Nitrous  Oxid-Oxygen  Apparatus     .         136-175 

CHAPTER    V 

ETHER 

History  of  the  Use  of  Ether  as  Anesthetic  ....        176-178 

Chemistry:  The  Term  Ether;  Properties  of  Ether;  Anesthetic 
Ether;  Precautions  in  Handling  Ether;  Sources  of  Impurities  in 
Ether ;  Standards  of  Purity  With  Which  Anesthetic  Ether  Should 
Comply;  Role  of  Alcohol  in  Ether;  Peroxids;  Aldehyd;  Physio- 
logical Action  of  the  Impurities  and  Administration  Means  to 
Avoid  Them '      .        .        178-184 

Special  Physiology:  Effects  Upon  Respiratory  System;  Effects 
Upon  Circulatory  System ;  Effects  Upon  Ners'ous  System ;  Effects 
Upon  Muscular  System;  Effects  Upon  Glandular  System  and 
Other  Structures;  Causes  of  Death  from  the  Administration  of 
Ether;  Stages  of  Ether  Anesthesia;  Elimination;  After- 
effects               184-199 

Administration  of  Ether:  The  Open  or  Drop  Methods;  The 
Mask;  Ethyl  Chlorid-Ether  Sequence  by  the  Drop  Method;  The 
Ethyl  Chlorid-Ether-Chlorofoi-m  Sequence;  The  Ethyl  Chlorid- 
Ether  Sequence  by  the  Closed  Method;  Chloroform-Ether  Se- 
quence;   Anesthol-Ether    Sequence   by   the    Drop    Method;    The 


xvi  CONTENTS 

PAGE 

Elhor  Ransch;  Tlie  Semi-Closed  Method;  Towel  and  Paper  Cones; 
The  Handkerchief  Method;  The  Closed  Method;  The  Nitrous 
Oxid-Ether  Sequence;  Technique  of  the  Nitrous  Oxid-Ether  Se- 
quence; Nitrous  Oxid-Ether-Chloroform  Sequence;  The  Vapor 
Method   of   Anesthesia;   Warmed   Ether  Vapor   .         .         .         199-231 

Vapor:  The  Open  Method;  Endopharyngeal  Anesthesia;  Oxygen- 
Ether  Administration;  Concentration  of  Ether  Vapor;  The  Closed 
Method ;  Amount  of  the  Anesthetic  Used ;  Care  of  the  Apparatus ; 
Hints;  Advantages;  Treatment  of  Accidents  ....         231-247 

Indications  and  Contraindications  of  Ether:  Indications;  Con- 
traindications ..........         247-249 


CHAPTER   VI 

ETHYL    CHLORID  ■ 

V^HEMiSTRY :  Chemical  History ;  Histoiy  of  Its  Use  as  an  Anesthetic ; 
Uses;  Prepai'ation ;  Properties;  Storage  and  Containers;  Impur- 
ities Which  May  Develop  in  Ethyl  Chloiid;  Detection  of  Im- 
purities in   Ethyl  Chlorid 250-258 

Physiology  :  Effects  upon  Respiratory  System ;  Effects  upon  Cii'cula- 
tory  System ;  Effects  Upon  the  Nervous  System ;  Effects  Upon  the 
Muscular  System;  Effects  Upon  the  Glandular  System;  Causes 
of  Death  Under  Ethyl  Chlorid  Anesthesia;  Stages  of  Anesthesia; 
Elimination;  After- Effects;  Comparison  With  Other  Anesthetic 
Agents 258-267 

Indications  and  Contraindications 267-269 

Administration  :  Experimental  Data ;  Methods  of  Administration ; 
Open  Method ;  Semi-Closed  Method ;  Closed  Method ;  Combi- 
nations  and   Sequences   .         .         .         .         .         .         .         .    •     269-279 

Bibliography 279-280 


CHAPTER   VII 

chloroform 

Chemistry:  History;  History  of  Its  Use  as  an  Anesthetic;  Prop- 
erties; Uses;  Preparation  of  Chloroform;  Impurities  Liable  to 
Be  Present  in  Chloroform ;  Stability  of  Chloroform ;  Decomposi- 
tion of  Pure  Chloroform;  Role  of  Alcohol  in  Anesthetic  Chloro- 
form; Character  of  Containers;  Stoppers  for  the  Containers; 
The  Changes  Which  Anesthetic  Chloroform  Undergoes  When  a 
CuiTent  of  Oxygen  is  Conducted  Through  It;  The  Decomposition 
of  Chloroform  Vapor  Upon  Exposure  to  Gas  Light,  Etc.,  Dur- 
ing Administration ;  Effect  of  Agitation  Upon  Anesthetic  Chloro- 
foi-m;  Standards  of  Purity  for  Anesthetic  Chloroform         ,         281-296 


CONTENTS  xvii 

PAGE 

Special  Physiology:  Effects  Upon  the  Respiratory  System;  Effects 
Upon  the  Circulatory  System ;  Effects  Upon  the  Nei"vous  System ; 
Effects  Upon  the  Muscular  System ;  Effects  Upon  the  Glandular 
System  and  Other  Structures;  (^auses  of  Death  from  tlie  Ad- 
ministration of  Cliloroform ;  Stages  of  Anesthesia;  Elimina- 
tion           297-310 

Indications  and  Contraindications:  Indications;  Contraindica- 
tions; After-Effects;  Comparison  with  Other  Agents  .         .         310-311 

Administration  of  Chloroform:  Drop  Method;  Other  Methods  of 
Administration ;  The  Roth-Drager  Oxygen  and  Chloroform  Ap- 
paratus; Vernon  Hareourt's  Inhaler;  Junker  Apparatus; 
Braun's  Inhaler;  Gwathmey  Three-Bottle  Vapor  Inhaler     .         311-324 

CHAPTER   VIII 

THE    selection    OF   THE   ANESTHETIC 

AND 
TECHNIQUE  FOR  SPECIAL  OPERATIONS 

Conditions  Affecting  Selection:  Inhalation  Anesthetics;  Safest 
Anesthetic;  Chloroform  with  Oxygen;  Value  of  Combinations 
and    Sequence   in    Anesthetics;    Safest    Sequences         .         .         324—326 

Rules  to  Be  Obeyed  in  Selecting  the  Anesthetic  :  Age ;  Heart 
Disease;  Pulmonary  Tuberculosis;  Obese  Patients;  Thin  Sub- 
jects; Athletes;  Alcoholics,  and  Other  Drug  Habitues;  Diseases 
of  the  Lungs;  Kidney  Diseases;  Cancer;  Nervous  Patients;  Epi- 
leptics; Insane  Patients;   Status  Lymphaticus    _  .         .         .         326-337 

Special  Operations:  Short  Operations;  Nitrous  Oxid;  Ethyl 
Chlorid;  Chloroform  and  Ether;  The  Mastoid;  The  Upper  Res- 
piratory Tract;  Excision  of  the  Tongue;  Cleft  Palate;  Sub- 
mucous Operations;  Adenoid  and  Tonsil  Cases;  Tracheotomy; 
Goiter  (Angina,  Ludovici,  Exophthalmos — Graves'  Disease) ; 
Amputations;  Operations  Upon  Fingers  and  Toes;  Circumcision; 
Rectal  Cases;  Obstetric  Cases;  Curettage;  Genito-urinary  Opera- 
tions; Laparotomy;  Gastro-enterostomy  and  Similar  Operations; 
Peritonitis   or  Intestinal   Obstruction   .         .         .         .         .         .         357 

Conclusions 357 

Bibliography 357-358 

CHAPTER   IX 

treatment  before,  during,  AND  AFTER  ANESTHESIA 

Duties  of  the  Anesthetist  in  Addition  to  Giving  the  Anes- 
thetic              361-362 

The  Anesthetist^s  Kit  :  Anesthetist's .  Motto ;  Mouth  Gag ;  Con- 
tents  of   Kit;    Emergency   Treatment   to   Insure   Breathing         362-363 


xviii  CONTENTS 

PAGE 

The  Management  of   Ordinary   Cases:     Preliminary  Treatment; 

Treatment  During  Anesthesia;   After-treatment   .         .         .         364-379 

Management  of  Difficult  and  Unusual  Cases:  Respiratoi-y ; 
Muscular;  Nervous;  Idiosyncratic;  Shock;  Post-Anesthetic 
Toxemia 379^15 


CHAPTER    X 

anesthesia  by  intratracheal  insufflation 

Definition 416 

History 416 

The  Apparatus  for  Intratracheal  Anesthesia  in  the  Human 
Being:  Apparatus  No.  I;  Apparatus  No.  II;  The  Catheter  or 
Tube  to  Be  Used;  The  Introduction  of  the  Tube  .         .         .         419^29 

The  Course  of  the  Anesthesia 429-430 

Errors  Which  May  Occur  in  Technique:     Accidents  and  How 

They  May  Be  Avoided 430 

Indications  for  Intratracheal  Anesthesia 431 

Bibliography 432 


CHAPTER   XI 
Part  I 

ANESTHESIA  BY   COLONIC  ABSORPTION   OF   ETHER 

Walter  S.  Sutton,  A.B.,  A.M.,  M.D.,  E.A.C.S. 

History 433-439 

The  Physiology  of  Colonic  Anesthesia 439-441 

Development  of  the  Method 441^4i4 

Sutton's  Apparatus:    The  Generator 444-449 

The  Afferent  and  Efferent  Tube  Systems     ....        449-450 
Technique  op  Method:     Preparation  of  Patient;  The  Administra- 
tion; After-treatment 450-453 

Discussion  of  Cases 453^57 

Conclusions:     Indications;  Contraindications;  Advantages;   Disad- 
vantages   457-458 


Part  II 
oil-ether  colonic  anesthesia 

History 458 

Animal  Experiments 458-460 

Remarks  on  the  Method 460 


CONTENTS  xix 

PAGE 

Prepaeation  of  the  Patient:     Preliminary  Medication  .        .         460-461 

Administration 461 

Control  of  the  Anesthesia 461-462 

Physiology 462 

Illustrative  Cases 463 

CHAPTER   XII 

sequestration  method  of  anesthesia 

History 467 

Technique 468 

Indications:    Brain  Surgery;  Goiter 469 

Contraindications 469 

Modifications  in  the  Method  :  Advantages ;  Disadvantages ;  Seques- 
tration with,  the   Upright  Position 470-475 

CHAPTER  XIII 

Part  I 
local  anesthesia 

James  F.  Mitchell^  M.D. 

History:  Adrenalin;  Cocain  Substitutes;  Arterial  Injection;  Ex- 
planation of  Poisonous  Action  of  Cocain;  Preparation  of  Solu- 
tions; Sterilizing  the  Solutions;  Novocain;  Urea  and  Quinin  Hy- 
drochlorid;  Syringes;  Indications  and  Scope  of  Local  Anes- 
thesia; Local  Versus  General  Anesthesia;  Mortality;  General 
Preparation  and  Technique;  Details  as  to  Comfort  of  Patient; 
After-treatment;  Healing;  Combination  of  Local  and  General 
Anesthesia 476-488 

Methods  :    Surface  Application ;  Infiltration ;  The  Regional  Method ; 

Venous  Anesthesia;  Arterial  Anesthesia         ....         488-493 

Special  Application:  Skin;  Head  and  Neck;  Face;  Ear;  Nose  and 
Accessory  Sinuses,  Tonsils;  Eye;  Neck;  Tracheotomy;  Larsnax; 
Thyroid;  Thorax  and  Breast;  The  Extremities;  Genito-urinaiy ; 
System;  Circumcision;  Rectum;  Gynecology;  Abdomen;  Inguinal 
Hernia 493-523 

Part  II 
intravenous  anesthesia 

Physiology 524 

Technique 524-532 

Mixed   Forms   op   Anesthesia 532-533 


XX  CONTENTS 

PAGE 

Blood    Changes •        533 

Urinary   Examination .        •        •        534 

CHAPTER   XIV 

LOCAL    ANESTHESIA    AS    APPLIED    IN    DENTISTRY 

Herrmann  Prinz_,  M.D.,  D.D.S. 

History •        •        535-536 

The  Hypodermic  Method 536 

Cold 537 

Mode  of  Application  op  Ethyl  Chlorid 537 

Cocain:  Preparation  of  Cocain  Solutions;  Sterilization  of  Solutions; 
Substitutes  Proposed  for  Cocain;  The  Hypodermic  Armamenta- 
rium           538-543 

Technique  of  Injection  :  The  Subperiosteal  Injection ;  Peridental 
Anesthesia;  Intra-osseus  Injection;  Perineural  Injection;  The 
Injection  into  the  Pulp;  Methods  of  Anesthetizing  the  Pulp         543-553 

CHAPTER   XV 

spinal  analgesia  and  spinal  anesthesia 

Introduction 554-555 

History:  Discoveiy  of  and  Experimentation  with  Cocain;  Experi- 
mentation with  Cocain  from  the  Neurological  Point  of  View 
with  Regard  to  Its  Analgesic  Effects  Upon  the  Sensory  Nerves, 
Including  the  Spinal  Cord;  Application  of  the  Analgesic  Effects 
of  Cocain  Upon  the  Cord  to  Surgical  Operations  Below  the  Dia- 
phragm; Extension  of  the  Surgical  Application  of  Spinal  Anal- 
gesia to  Parts  of  the  Body  Above  the  Diaphragm ;  Experimenta- 
tion with  Other  Agents '     .         .         555-563 

Anatomical    and    Physiological    Considerations:      Origin;    Vol- 
ume; Specific  Gravity;  Movements;  Pressure;  Diffusion       .         563-572 
Course,  Extent,  and  Duration  of  Analgesia:     Course;   Extent; 

Duration  . 572-577 

Accompanying  Phenomena:     Subjective;  Objective  .         .        .        577-582 

Post-operative  Phenomena 582-586 

Indications  and  Contraindications 586-594 

Advantages  and  Disadvantages:     Advantages;   Disadvantages         594-596 

Deaths 596-599 

Analgesic  Agents  :     Cocain ;   Tropoeocain ;   Stovain  ;  Novocain         599-604 

Sterilization  of  the  Analgesic  Agent 604-605 

Sites  of  Injection 605-612 

The   Patient:      Preliminaiy   Preparation   of   Patient;    Position    of 

Patient 612-614 


CONTENTS  xxi 

PAGK 

Apparatus  and  Materials  .        .        .        •  ,     •        •        •        •        014-617 

Technique    of    Injection -        017-623 

Additional  Illustrative  Case  Reports      .        .        .        •        •        623-626 
Conclusions 627 

CHAPTER  XVI 

ELECTRIC  ANALGESIA^   SLEEP^   AND  RESUSCITATION 

Louise  G.  Robinovitch,  B.  esL.,  M.D.  (Paris) 

History  :  Electric  Source  and  Technique ;  Application  in  Man ;  Con- 
traindications;  Electric  Analgesia  and  Sleep  in  Wireless  Circuits; 
Conclusions 628-63C 

Electric  Analgesia  and  Electric  Resuscitation  After  Heart 
Failure  Under  Chloroform  or  Electrocution:  Exclusion  of 
the  Head;  Kind  of  Current  Used;  Procedure;  Limitations;  Ap- 
plication in  Accidental  Electrocution;  Application  in  Surgery; 
Clinical  Applications 637-643 

CHAPTER  XVII 
Part  I 

MENTAL  influence  IN  ANESTHESIA 

James  J.  Walsh,  M.D. 

Hypnotism:  Anesthesia  in  Hypnotic  States;  Chemical  Anesthetics 
and  Hypnotism;  Advantages  of  Hypnotism  in  Anesthesia;  Hyp- 
notism and  Childbirth;  Hypnotism  in  Minor  Operations;  Ad- 
vantages of  Hypnotism ;  Charlatanism  and  Hypnotism  .         .         644—649 

Suggestion:  Suggestion  Instead  of  Hypnotism;  Psychic  Influences 
and  Surgical  Anesthesia ;  Local  Anesthesia  and  Mental  Influence ; 
Mental  Influence  as  a  Valuable  Auxiliary;  Deep  Breathing  and 
Concentration  of  Mind;  Preliminary  Medication  and  Mental 
Influence ■.        .        649-653 

Part  II 

HYPNOSIS  IN   anesthesia 

H.  W.  Frink,  M.D. 

Hypnosis:  The  Different  Degrees  of  Hypnosis  and  Some  of  the 
Phenomena  Accompanying  Them ;  Factors  Which  Influence  Sug- 
gestibility ;  The  Attitude  of  the  Hypnotist ;  Methods  of  Inducing 
the   State  of  Hypnosis;   The   Induction  of  Anesthesia         .         653-665 


CONTENTS 


CHAPTER  XVIII 

THERAPEUTIC  USES  OF  INHALATION  ANESTHETICS 

PAGE 

Anesthetic  Treatment  for  Special  Conditions:  In  Renal  and 
Biliary  Colic;  In  Cases  of  Acute  Pain  or  Shock;  In  the  Passage 
of  Renal  or  Biliary  Calculi;  Extreme  Irritability  of  the  Central 
Nervous  System;  Convulsions  of  Infancy  and  Childhood;  Puer- 
peral Eclampsia;  In  Anemic  Convulsions;  Convulsions  and  Seiz- 
ures Depending  Upon  Poisoning,  and  Cerebral  Diseases;  Use  in 
Diagnosis;  Insomnia  or  Extreme  Restlessness;  Acute  Mania; 
Some  Miscellaneous  Applications  of  Ethyl  Chlorid       .         .         666-671 

Other  Uses  of  Agents  Employed  in  the  Administration  of  An- 
esthetics :  Ether  in  the  Treatment  of  Infections ;  Ether  Irriga- 
tion  of   the   Abdomen 671-674 


CHAPTER  XIX 

the  medico-legal  status  of  the  anesthetist 
John  W.  H.  Crim 

Introduction:  Police  power;  The  Medical  Profession  Established; 
Contest  Between  the  Schools  of  Medicine;  The  Status  of  the 
Physician 675-680 

The  Physician's  Liability:  Ethical  Liability  of  the  Physician; 
The  Civil  Liability  of  the  Physician;  Malpractice;  Liability  of 
the  Specialist;  The  Criminal  Liability  of  the  Physician;  Gross 
Ignorance  or  Negligence ;  Statutory  Liability  ....         680-687 

CHAPTER   XX 

A  LIST  OF  anesthetics 

Including  General  Anesthetics^  Local  Anesthetics^  and  Anes- 
thetic Mixtures^  Both  Past  and  Present,  with  Synonyms        688-840 

CHAPTER   XXI 

statistics 

Introduction 841-843 

Collateral  Information:  Local  Anesthesia;  Nitrous  Oxid  Alone 
or  with   Air;   Nitrous   Oxid  with   Oxygen;   Anesthol-Ether   Se- 


CONTENTS  xxiii 

PAGE 

quence;  Chloroform-Ether  Sequence;  Nitrous  Oxid-Ether  Se- 
quence; Anesthol;  Ether,  Drop  or  Vapor;  Ethyl  Chlorid- Ether 
Sequence;  Ethyl  Chlorid;  Chloroform-Oxygen;  Chloroform,  Drop 
or  Vapor;  Intratracheal  Anesthesia;  Oil  of  Bitter  Orange  Peel- 
Ether  Sequence,  Comparison  of  Amerisan  Statistics  for  1905-1911 
with  Those  for  1892;  Comparison  of  American  with  European 
Statistics;  American  Statistics,  1905-1912,  Inc.  .  .  .  844-856 
Conclusions 857 


APPENDIX   I 

ETHTIi    ETHER 

History  of  Ethyl  Ether 858-860 

Manufacture  of  Ether:     Ether  from  "Methylated"  Alcohol;  Ether 

from  Ethylene;  Theories  of  Etherification  ....  860-863 
Purity  of  Ether:  The  Commercial  Purification  of  Ether;  Verified 
Tests  for  Proving  Purity  of  Anesthetic  Ether;  Role  of  Water  in 
Anesthetic  Ether;  Explanation  of  Changes  Liable  to  Occur  in 
Ether  Improperly  Stored;  The  Purification  of  Ether  Remnants 
with  the  View  of  Removing  Aldehyd  in  Particular;  Acidity  of 
Ether  and  Effect  Thereon  of  the  Container;  Physiological  Con- 
sideration in  Reference  to  Small  Amounts  of  Impurities ;  The  De- 
grees of  Purity  of  American  Ethyl  Ethers  Used  for  Anesthesia    864r-S70 


APPENDIX   II 
chloroform: 

History  of  Chloroform .        .        871-873 

Preparation  of  Chloroform  :    From  Ethyl  Alcohol ;  From  "Methyl- 
ated   Spirit";    From   Acetone;    From   Methane;    From    Carbon 

Tetrachlorid 873-875 

.  Varieties  of  Chloroform  of  European  Make  :    Chloral  Chloroform ; 

Chloroform   Pictet;    Chloroform   Anschiitz   .....         876 

Purification    of    Chloroform 877-883 

The  Decomposition  of  Chloroform:     The  Changes  Which  Chloro- 
form Undergoes  Upon  Exposure  to  Air         ....         883-888 
Verified  Tests  for  Purity  of  Anesthetic  Chloroform:     Odor; 
Residue;  Specific  Gravity;  Organic  Impurities;  Acetone;  Aeetal- 
dehyd;    Acidity;    The    Decomposition    Products    of    Anesthetic 

Chloroform 889-890 

Degrees  of  Purity  of  American  Chloroforms        ....        891 


CONTENTS 


APPENDIX   III 

OXYGEN 

PAGE 

History  of  Oxygen 893 

Methods  op  Manufacturing  Medical  Oxygen        ....  893 

Impurities  That  May  Be  Present  in  Oxygen        ,        .        .      " .  894 

Purity  op  Commercial  Medicinal  Oxygen 895 

Standards  of  Purity  That  Should  Be  Required  for  Oxygen  to 

Be  Used  in  Medicine 895 


Index ,        ,        »        .        897 


LIST    OF  ILLUSTRATIONS 

FIG.  PAGE 

1.  Henry   Hill    Hickman 6 

2.  Crawford    W.    Long        .         .         .         ,       ■  .         .         .         .         .  9 

3.  Horace  Wells  ...........  11 

.  4.     William  T.   G.  Morton 12 

5.  The  original  Morton  inhaler  .         .         .         .         .         .         .         .13 

6.  The  original  Morton  inhaler  ........  14 

7.  One  of  the  earliest  operations  imder  ether  at  the  Massachusetts 

General  Hospital     .         . 15 

8.  Charles  T.  Jackson  ..........  17 

9.  Sir  James  Y.  Simpson  .........  21 

10.  Bust  of  Sir  James  Y.  Simpson 22 

11.  Gwathmey's   vapor   apparatus   with   the   tube   leading   from    the 

heater  in  actual  practice         .......  71 

12.  Gwathmey  vapor  inhaler  with  heating  apparatus         ...  72 

13A-C.     Boothby  Curves 74 

13d-e.     Boothby  Curves  ..........  75 

14.  Oxygen  passing  through  rubber  coil  immersed  in  hot  water         .  89 

15.  Intra-abdominal   administration  of  oxygen  in  case  of  intestinal 

adhesions          ..........  89 

16.  Suturing  of  the  peritoneum     ........  90 

17.  Aponeurosis  united  with  inteiTupted  sutures         ....  91 

18.  Superficial  fascia  united           ........  92 

19.  Tube    withdrawn;    peritoneal    purse-string    tied;    knot    beneath 

aponeurosis      ..........  93 

20.  Gatch  nitrous  oxid-oxygen  apparatus     .         .         .         .         .         .  104 

21.  Chart  showing  pulse  and  respiration  with  rebreathing         .         .  105 

22.  Chart  of  the  pulse,  respiration,  and  blood-pressure  during  anes- 

thesia of  two  hours  and  fifteen  minutes'  duration         .         .  106 

23.  Chart  showing  value  of  rebreathing  during  operation         .         .  107 

24.  Tracing  obtained  froni  the  pyloric  ring  of  a  frog  suspended  in  a 

moist  chamber  into  which  ether  vapor  and   carbon   dioxid 

could  be  passed       .........  114 

25.  Gardner  Q.  Colton 119 

26.  Guedel's   apparatus   for   the  self-administration   of  nitrous  oxid 

and  air    ...........  138 

27.  Guedel's  apparatus,   showing  detail   construction   of   respiratory 

valve •        .        .        .  139 

XXV 


xxvi  LIST    OF    ILLUSTRATIONS 

FIG.  PAGE 

28.  Diagrammatic   sketch   showing   simple   method   of   administering 

nitrous   oxid  and   oxygen  with  indefinite  quantities  of  the 

agents  used     ..........  144 

29.  Davis  nitrous  ■  oxid-oxygen  apparatus     ......  145 

30.  Davis    apparatus    case    . .  146 

31.  Davis  nitrous  oxid-oxygen  apparatus  with  vapor  apparatus  dis- 

connected ...........  146 

32.  Davis   nitrous    oxid-oxygen    apparatus   showing  heater         .         .  147 

33.  Davis  nitrous  oxid-oxygen  apparatus  with  Gwathmey  vapor  in- 

haler           147 

34.  Davis  nitrous  oxid-oxygen  apparatus  with  Gwathmey  vapor  in- 

haler.   With  cover 148 

35.  Davis   nitrous   oxid-oxygen   apparatus   with    Gwathmey   inhaler. 

Without  cover 148 

36.  Coburn's  apparatus  with  anesthetic  table  and  cylinders  attached  149 

37.  Coburn's  apparatus :  face-piece  and  bag         .....  149 

38.  Coburn's  apparatus:  face-piece  and  electric  heater         .         .         .  150 

39.  Gwathmey's    nitrous    oxid-oxygen    apparatus         ....  150 

40.  Gwathmey  oxygen  Y-piece  adapted  for  Bennett's,  Furniss'       or 

Gwathmey  inhaler 151 

41.  Teter  nitrous   oxid-oxygen   apparatus 152 

42.  The  Teter  vapor  warmer  . 153 

43.  Teter's  face  mask 154 

44.  Teter  ether  attachment 154 

45.  Teter  nasal  inhaler 155 

46.  Teter's  auxiliary  tube  for  administering  nitrous  oxid  and  oxygen 

through  the  mouth  .........  155 

47.  Teter  nitrous  oxid-oxygen  apparatus  with  nasal  inhaler  in   use  156 

48.  Teter  nitrous  oxid-oxygen  apparatus  with  nasal  inhaler  in  use, 

with  surgeon  operating  ........  156 

49.  Teter's  nasopharyngeal  tubes  for  nitrous  oxid  and  oxygen         .  157 

50.  The  Ohio  monovalve 158 

51.  Ohio   small  nitrous  oxid  inhaler 159 

52.  Connell's  anesthetometer          ........  160 

53.  Pressure  gauges  for  large  tanks  of  nitrous  oxid  and  oxygen         .  161 

54.  Boothby  and  Cotton  apparatus  set  up  .         .         .         .         .         .  162 

55.  Boothby  and  Cotton  apparatus  folded 163 

56.  Boothby    and    Cotton    face-mask 166 

57.  Gwathmey-Woolsey  nitrous  oxid-oxygen  apparatus       .         .         .  171 

58.  Gwathmey-Woolsey  nitrous  oxid-oxygen  apparatus  with  cylinders 

attached 172 

59.  Gwathmey-Woolsey   nitrous    oxid-oxygen    apparatus   as    used   in 

general  surgeiy       .........  174 

60.  Gwathmey-Woolsey   nitrous    oxid-oxygen    apparatus    in    adenoid 

and    tonsil    operations    .         . 174 

61.  The    pupillometer 195 

62.  Dropper  from  original  can 200 

63a.     Chloroform  and  ether  containers  for  the  drop  method         .         .  200 


LIST    OF    ILLUSTRATIONS  xxvii 

FIG.  PAGE 

63b.     Chloroform  and  ether  containers  for  the  drop  method         .         .  201 

64.  Ether  containers  with  dropper       .......  201 

65.  Glass  container  for  holding  ether 202 

66.  Lumbard's  rubber  ether  blanket  and  elastic  mask  holder         .         .  202 

67.  Yankauer-Gwathmey  drop  and  vapor  mask    .....  203 

68.  The   Ferguson   mask 204 

69.  Davis  dropper  for  insertion  in  original  container  ....  206 

70.  The   ether   rausch 210 

71A-0.     The  handkerchief  method 213-215 

72.  Cone   adjusted   to   the   face 216 

73.  Allis  inhaler  with  soft  rubber  cover  for  semi-open  method         .  216 

74.  Allis  inhaler,  metal  with  rubber  cushion  for  face  and  gauze  dia- 

phragm   ...........  216 

75.  The    Esmarch    inhaler 217 

76.  Comparative   size   of  bores   of   inhalers         ...         .         .         .  217 

77.  Bennett's  nitrous  oxid-ether  apparatus :   ether  inhaler         .         .  218 

78.  Bennett's  nitrous  oxid-ether  apparatus :  gas  inhaler         .         .         .  218 

79.  Bennett's  nitrous  oxid-ether  apparatus :  gas  and  ether  inhaler         .  218 

80.  The  Gwathmey  inhaler  open  ........  219 

81.  The  Gwathmey  inhaler  closed  . 219 

82.  Gwathmey  nitrous  oxid-ether  apparatus 220 

83.  The  Fumiss   nitrous   oxid-ether  apparatus 221 

84-85.     The  Davis  apparatus  showing  inhaler  for  ethyl  chlorid-ether 

sequence  by  the  closed   drop  method   .....  222 

86.  Davis   apparatus   for  gas-ether   or  ethyl   chlorid-ether  by   drop 

method     .         .         .         .         .         .         .         .         .         •         •  223 

87.  Davis  heater  for  ether  and  nitrous  oxid  and  oxygen     .         .         .  223 

88.  Davis  heater  with  the  Gwathmey  three-bottle  vapor  inhaler         .  224 

89.  Vapor   mask 224 

90.  Top  of  three-bottle  vapor  inhaler  .......  225 

91.  Diagram  of  top  of  three-bottle  inhaler  ......  225 

92.  Jackson's  speculum  in  position  for  the  introduction  of  the  endo- 

tracheal catheter 226 

93.  Endopharyngeal  tubes  for  maintaining  insufflation  anesthesia         .  227 

94.  Glass  nasal  tubes  for  general  anesthesia       .....  227 

95.  Junker  inhaler         ..........  228 

96.  Lumbard's  glass  nasal  tubes 229 

97.  Three-bottle  vapor  apparatus  connected  with  electric  heater  and 

vapor  mask 230 

98.  Foot    pump    attached    to   three-bottle   vapor   inhaler   .         .         .  230 

99.  Gwathmey  method  of  administering  warmed  vapor  through  the 

nose 

100.  Ether  vapor  mask  encircled  by  a  towel  held  in  place  by  a  safety- 

pin    ............ 

101.  Same  as  Figure  100  with  outer  fold  of  towel  dropped  as  patient 

reaches    surgical    anesthesia   ....... 

102A-B.     Methods  of  holding  jaw  forward  so  as  to  maintain  an  open 

airway 233 


231 


232 


232 


LIST    OF    ILLUSTRATIONS 


PIG. 

103.  Pinneo's  ether  vapor  apparatus,  diseonneeted 

104.  Pinneo's  ether  vapor  apparatus  in  use  ...... 

105.  Pinneo's  mouth  tube  for  continuous  vapor  anesthesia  . 

106.  Endopharyilg-eal    insufflation    and    mouth    tube    combined     . 

107.  Three-bottle  vapor  appai^atus  attached  to  oxygen  tank  . 

108.  Chart  I,  showing  the  necessary  percentage  of  ether  vapor  for 

the  endopharyngeal  or  endotracheal  administration 

109.  Chart  II,  showing  the  most  advantageous  ether  pressure  . 

110.  Administration  of  warmed  ether  vapor  by  the  closed  method 

111.  Diagrammatic   sketch   of   the  nitrous   oxid-ether   vapor  sequence 

112.  Sealed  tubes  of  ethyl  chlorid 

113.  Double  end  ethyl  chlorid  tube  .  ... 

114.  Automatic  closing  tube  for  ethyl  chlorid 

115.  Automatic  closing  tube  for  ethyl  chlorid 

116.  Flexible  spraying  nozzle  ........ 

117.  Ferguson's   ethyl  chlorid  tubes  for  general   and  local  anesthesia 

118.  The  Gebauer  container  for  ethyl  chlorid  .... 

119.  Technique  of  ethyl  chlorid  measure-dropper  . 

120.  Martin  Ware's  apparatus  for  administering  ethyl  chlorid 

121.  Ethyl  chlorid  by  the  closed  method  ..... 

122.  Davis  ethyl  chlorid-ether  inhaler:   closed  drop  method 

123.  The   Pilling  chloroform   dropper  .... 

124.  A  chloroform  dropper  which  should  never  be  used 

125.  The  Roth-Drager  apparatus  ..... 

126.  The  Roth-Drager  apparatus  ..... 

127.  The  Roth-Drager  apparatus  .         .         ... 

128.  Vernon  Harcourt's  inhaler,  complete  with  face-piece,  bottle 

beads        

129.  Junker's  apparatus  ...... 

130.  Hewitt-Mason's   mouth-gag  with   anesthetic   tubes 

131.  The  Gwathmey  three-bottle  vapor  inhaler,  niouth  gag,  with  hollow 

tubes  attached 

132.  The  water  suction  apparatus  for  adenoid  and  tonsil  operations 

133.  Pump  attached  to  spigot  with  water  turned  on     . 
134A-J.     Dr.  French's  chair  table 

135.  Supporting  jaw  to  maintain  free  ainvay  with  two  fingers  on  the 

carotid  artery  .         .         .         .         .         . 

136.  Preparing  to  lift  patient       .         .         .         . 

137.  Carrying  patient  head  high   .         .         .         . 

138.  Hewitt's  artificial  airway 

139.  Ferguson's  modification  of  Hewitt's  airway    . 

140.  Connell's  breathing  tube 

141.  The  Lewis  pendulum  swing  .         .         .         .         . 

142A-B.     Artificial  respiration 

143A-J.     Draeger's  pulmotor 

144.  The  lung  motor 

145.  Meltzer's    apparatus   for   artificial    respiration    with    pharyngeal 

tube   and   foot   belloAvs 


and 


346- 


396- 


PAGE 
234 
235 
236 
236 
240 

241 
242 
244 
245 
254 
254 
254 
254 
254 
255 
256 
256 
273 
274 
275 
312 
313 
318 
319 
320 

321 
321 
322 

334 

343 

344 

-351 

361 
377 
378 
391 
391 
392 
393 
395 
-399 
399 

400 


tubes 


LIST    OF    ILLUSTRATIONS 

FIG. 

146.  Meltzer's  apparatus  for  artificial  respiration  with  mask  atiaclicd 

to  oxygen  tank         ....... 

147.  Blood-pressure  tracing  from  an  etherized  dog 

148.  Crile's   abdominal  hysterectomy  chart   .... 

149.  Crile's   thyx'oidectomy   chart   ...... 

150.  Crile's  chart  of  mortality  rate  ..... 

151.  Operations  under  anoci-association         .... 

152.  Technique  of  abdominal  operation  under  anoci-association 

153.  Blood  pressure  apparatus  as  used  by  McKeson  . 

154.  McKeson's  blood  pressure   chart  No.  3908   ... 

155.  Meltzer's  simple  apparatus  for  intratracheal  insufflation 

156.  Elsberg's  apparatus   for  hospital   use   .... 

157.  Diagram  to  explain  the  parts  of  Elsberg's  apparatus  No.  1 

158.  Elsberg's  simplified  portable  apparatus  for  intratracheal  insuf- 

flation .         .         .         .         .         .         .         .         . 

159.  Elsberg's  apparatus         ....... 

160A-B.     Janeway's   apparatus  ...... 

161.  Fischer's  apparatus  ....... 

162.  Ehrenfried's  apparatus  for  intratracheal  etherization  . 

163.  Cotton-Boothby   introducing   cannula,    Ehrenfried's   modification, 

for  soft  rubber  tubes       ...... 

164.  Ehrenfried's  introducing  forceps  for  stiff  or  soft  rubber 

165.  Jackson's    direct    laiyngoscope 

166.  Elsberg's  clip  to  hold  the  intratracheal  tube  in  place  . 

167.  Latest  form  of  colonic  anesthesia  apparatus  .         .         . 

168.  Apparatus   for  administering  ether  per  rectum  . 

169.  Apparatus  of  Ligueu,  Morel,  and  Verliac  .         .         '. 

170.  Leggett's  apparatus         ....... 

171.  Parts  of  vapor  generator        .         .         .         . 

172.  Schematic  section  of  vapor  generator  .... 

173.  Sectional  view  of  manometer  ...... 

174.  Sectional  view  of  H-tube         ...... 

175.  Simple    form    of    Sutton's    apparatus    .... 

176.  Complete  apparatus  with  oxygen  tank  .         ,         .         . 

177.  Combination  clip  with  hook  .         .         .         .         ... 

178.  Check  valve  used  on  afferent  tube  when  coughing  is  to  be  permitted 

179.  Sketch  of  pipe-line  system  with  safety  valve  Avater  monometer 

attached    .         .         .         .         .         .         .         .... 

180.  Gwathmey  rectal   irrigating  tube 

180a.  Showing  patient  in  position  for  oil-ether"  administration 

181.  Sequestration  method   as   used  in   French's   clinic 

182.  Syringes   and   solutions   bottles   for  local   anesthesia    . 

183.  Showing  triangular  pad  supporting  back  and  sandbag  as  support 

of    feet    ........... 

184.  Method  of  applying  rubber  bandages  for  Bier's  venous  anesthesia 

185.  Syringe   and   cannula   for   Bier's   venous    anesthesia    . 

186.  Beginning  of   skin  wheal       ........ 

187.  Continuation   of  wheal  ....       ..         .         .         ,         . 


XXIX 

PAGE 

400 

401 
405 
406 
406 
407 
407 
411 
412 
417 
419 
420 

421 
422 
424 
425 

426 

426 

427 
428 
428 
438 
441 
442 
442 
445 
445 
446 
447 
447 
448 
450 
450 

451 
461 
461 

474 
481 

487 
491 
491 
494 

494: 


XXX  LIST    OF    ILLUSTRATIONS 

FIG.  PAGE 

188.  Congestion  of  wheal  and  beginning  of  deep  injection  .         .         .  495 

189.  Anesthetization  of  skin  by  subcutaneous  injection,  showing  wide 

area  of  distribution  through  two  injection  points  .         .         .  495 

190.  Injection  of  the  deeper  structures  through  the  same  points  as  in 

Figure  189 496 

191.  Nerve  supply   of  face  and  scalp  from  the  cervical  plexus  and 

trigeminal  nei-ve       .........  497 

192.  Showing  the  area  of  anesthesia  produced  by  a  cross  strip  of  sub- 

cutaneous injection  above  the  supra-orbital  ridge,  blocking 

the  nei^e  supply  from  below  .......  498 

193.  Sensory  innervation  of  the  mucous  membranes  of  the  head         .  499 

194.  Sagittal  section  through  the  foramen  ovale  .....  500 
195     Position  and  size  of  skin  wheal  for  puncture  of  Gasserian  ganglion  500 

196.  Front  and  side  views  showing  the  direction  of  the  cannula  to  reach 

the   Gasserian   ganglion  according  to   Haertel's  method       .  501 

197.  Area  of  anesthesia  produced  by  blocking  the  cervical  plexus  at  the 

posterior   border    of   the    sternomastoid   muscle    .         .         .  501 

198.  Blocking  the  cervical  plexus  at  posterior  border  of  sternomastoid 

muscle .  503 

199.  Incision  through  skin  and  platysma  muscle  showing  almost  blood- 

less field 504 

200.  Operation  completed;  wound  closed       ......  505 

201.  Cross-section  of  forearm,  5  cm.  above  the  wrist  .         .         .         .  507 

202.  Distribution  of  the  nerves  of  the  upper  extremity  to  the  skin 

anteriorly    and    posteriorly .  508 

203.  Cross-section   through   base   of  finger 509 

204.  Cross-section  through  leg  just  above  ankle,  showing  direction  of 

needle  for  perineural  injection  of  posterior  tibial  nerve         .  509 

205.  Injection  of  skin  incision  for  hallux  vagus     .         .         .         .         .  510 

206.  Deep  in'ection  between  metatarsals 510 

207.  Injection  of  periosteum 511 

208.  Resection  of  bone 512 

209.  Insertion  of  fascial  flag  . 513 

210.  Anesthetization  of  prepuce  in  circumcision 514 

211.  Anesthetization  of  base  of  prepuce  in  circumcision         .         .         .  514 
212     Showing  separate  injection  of  fraenum  in  circumcision  .         .         .  515 

213.  Anesthetization    of    anal   and   rectal   regions         ....  516 

214.  Sagittal  section  of  rectum,  showing  the  direction  of  the  needle 

in  anesthetizing  the  rectum 517 

215.  Relations  of  the  inguino-scrotal  nerves  to  the  hernia  incision       , .  520 

216.  Sketch  showing  usual  situation  of  nerves  as  exposed  after  division 

and  reflection  of  the  aponeurosis  of  external  oblique  muscle  521 

217.  Scheme  of  injection   in   large   umbilical  hernia  ....  522 

218.  Holder  for  arm 525 

219.  Vein  exposed  and  ligated  distally 526 

220.  Cannula  introduced   and  tied   in  the  vein 527 

221A-B.     Salvarsan  method  of  introducing  the  needle  ....  528 

222.    Patient  under  anesthesia  by  the  intravenous  method  .        .        .  530 


LIST    OF    ILLUSTRATIONS  xxxi 

FIG.  PAGE 

223.  Another  model  apparatus  for  intravenous  anesthesia  .         .         .  531 

224.  Application  of  the  ethyl  chlorid  spray 538 

225.  Outfit   for   preparing   the   hypodermic   solution   ....  542 

226.  Dental   hypodermic   syringe    ........  542 

227.  Method  of  injection  into  the  labial  subperiosteal  gum  tissue         .  544 

228.  Method  of  injecting  into  the  palatine  subperiosteal  gum  tissue     .  545 

229.  Subperiosteal  injection   about  an  upper  cuspid  ....  546 

230.  Subperiosteal   injection   about   an   upper  molar   ....  546 

231.  Peridental  injection  about  an  upper  bicuspid         ....  547 

232.  Perineural  injection  upon  the  buccal  side  of  the  upper  jaw         .  548 

233.  Perineural  injection  upon  the  hard  palate  .....  550 

234.  Perineural   injection    near   the   mandibular   foramen    .         .         .  551 

235.  Operation  under  way  for  removal  of  tumor  of  abdominal  wall 

under  spinal  analgesia       ........  573 

236.  Second  operation,  same  analgesia,  same  patient  as  in  Figure  235  573 

237.  Same  patient  as  in  Figures  235  and  236.     At  end  of  operation  574 

238.  Enlarged    picture    of    patient's    face    showing   facial    expression  575 

239.  Amputation  of  foot  just  above  ankle  joint  under  spinal  analgesia  578 

240.  Inguinal  hernia,  inherent  intestine,  adhesions  being  pulled  apart 

under  spinal   analgesia  ........  579 

241.  Same   as   Figure   240,    head   elevated 579 

242.  Same  patient  at  end  of  operation  .......  580 

243.  Diagram  of  cross-section  opposite  the  fourth  lumbar  interspace  606 

244.  Diagram  of  a  cross-section  through  the  dorsal  spine  .         .         .  606 

245.  Spinal  cord  enclosed  in  unopened  dural  sheath  lying  within  verte- 

bral  canal 608 

246.  Posterior  wall  of  vertebral  canal  has  been  removed  and  dural 

sheath  opened  to  expose  spinal  cord  and  dorsal  roots  of  at- 
tached nerves  ..........  608 

247.  Upper  part  of  spinal  cord  within  dural  sheath,  which  has  been 

opened   and  turned   aside 609 

248.  End  of  spinal  cord  with  roots  of  lower  nerves  descending  in  cauda 

equina  to  gain  their  respective  foramina       ....  610 

249.  Schematic  picture  showing  landmarks  used  in  locating  space  be- 

tween  third   and   fourth   lumbar   vertebrae   ....  611 

250.  Schematic    picture   showing   needle   inserted   between   third    and 

fourth  lumbar  vertebrae  of  the  spinal  canal,  but  below  the 

cord 611 

613 
614 


251.  Patient  in  sitting  posture  ready  for  spinal  puncture  . 

252.  Injection  being  made  with  patient  in  recumbent  position  . 

253.  Table  containing  instruments  and  materials  used  in  giving  spinal 

analgesia 615 

254.  Bainbridge's   syringe   and   needle   .......     615 

255.  Babcock's  needle  for  spinal  analgesia  ......     615 

256.  Sterilizing  the  apparatus         . 616 

257.  Puncture  site  area  painted  with  iodin 618 

258.  Sterilizing  sheet,  patient   draped,   and  window  made  at   site  of 

puncture 619 


XXXll 


LIST    OF    ILLUSTRATIONS. 


FIG. 

259.  Locating   the   site   for    puncture    .         .         . 

260.  Applying  ethyl  chlorid  and  incising  the  skin  . 

261.  Showing  direction  of  needle  about  to  enter  spinal 

262.  Cerebrospinal  fluid  escaping  .... 

263.  Injecting  solution   . 

264.  Cotton  and  collodion  dressing  on  puncture  point 
265-268.     Myograms  No.  5  to  No.  8.    Unipolar  method 

269.  Myogram  No.  9.     "Unipolar" 

270.  Myogram    No.    10.      "Wireless"    . 

271.  Myogram    No.    11.      "Wireless"    . 

272.  Tracing   No.    1.      Made    during   usual    form    of 

caused  by  intensive  chloroforming  in  a  dog 

273.  Tracing  No.  2.     Primary  cardiac  syncope  in  dog 

274.  Tracing  No.  3.    Primary  cardiac  syncope  in  dog 

275.  Suggesting   rigidity   of   the   arm    . 

276.  Beginning  of  sleep  by  Frink's  method 

277.  Beginning  of  sleep  by  Frink's  method 

278.  Induction  of  anesthesia  . 

279.  Anesthesia  in  a  case  of  acute  mania 

280.  Apparatus  used  by  Baskerville  and  Neidle 

281.  Graph  showing  the  heat  generated  by  mixing  ether 

282.  Graph   showing  densities   of   I'esidues    . 

283.  A  calibrated  pykonometer  of  25  c.  c.  capacity 


canal 


apparent 


and 


death 


chloroform 


PAGE 

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621 
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632 

640 
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641 
660 
661 
662 
664 
668 
706 
707 
709 
865 


ANESTHESIA 

CHAPTER    I 
THE    HISTORY    OF    ANESTHESIA 

Introductory  Eemarks:  Ancient  History;  Beginning  of  the 
Christian  Era;  Asiatic  Sources;  Middle  Ages;  Hypnotism;  Real  Be- 
ginnings of  Surgical  Anesthesia;  Discovery  of  Ether  Anesthesia;  The 
Discovery  of  Nitrous  Oxid  for  Surgical  Anesthesia. 

Ether:  Morton;  First  Public  Demonstration;  Letheon;  Anes- 
thesia in  England. 

Chloroform:  Theological  Opposition  to  the  Use  of  Anesthetics; 
The  Early  Use  of  Chloroform  in  Midwifery;  Some  Physicians  Believe 
in  Pain;  Prejudice  Developed  against  Chloroform;  Scientific  Adminis- 
tration of  Ether  and  Chloroform;  Efforts  to  Overcome  Objections  to 
Chloroform  by  Use  of  Substitutes  and  Improved  Inhalers;  A.C.E.  Mix- 
ture; Substitutes;  First  Vapor  Inhaler;  Nitrous  Oxid  More  Generally 
Appreciated;  Nitrous  Oxid  and  Oxygen;  Discarding  Chloroform  for 
Ether;  Improved  Methods  for  Administering  Ether;  Warmed  Ether 
Vapor;  Chloroform  Condemned;  Medication  before  Anesthesia;  The 
Use  of  Chloroform  Accompanied  with  Danger ;  Chloroform  and  Oxygen ; 
Combinations  and  Sequences  in  Anesthetics;  Ethyl  Chlorid;  Impor- 
tance of  Trained  Anesthetists. 

Bibliography, 

INTRODUCTORY  REMARKS 

Sacred/  profane,  and  mythological  literature  abound  in  incident, 
fact  and  fancy,  showing  that  from  the  earliest  times  man  has  sought 
to  assuage  grief  and  pain  by  some  means  of  dulling  consciousness.  In 
these  attempts  many  methods  and  diverse  agents  have  been  employed. 
The  inhalation  of  fumes  from  various  substances,  weird  incantations, 
the  external  and  internal  application  of  drugs  and  many  strange  con- 

'  The  Bible  and  Talmud  contain  references  to  the  ancient  practice  of  induc- 
ing sleep  by  artificial  means. 

1 


2  ANESTHESIA 

coctions^  pressure  upon  important  nerves  and  blood  vessels,  the  "laying 
on  of  hands"  or  animal  magnetism,  mesmerism,  hypnotism,  and  the  many 
methods  which  come  within  the  pale  of  modern  science,  as  well  as 
pseudo-science,. have  played  their  part  in  the  evolution  of  anesthesia. 

It  is  intended  in  this  section  to  give  a  brief  review  of  what  is  now 
known  as  general,  or  inhalation,  anesthesia.  The  various  other  measures 
for  the  dulling  of  consciousness  and  for  the  induction  of  partial  or  com- 
plete insensibility  to  pain  are  fully  discussed  under  their  respective 
heads,  and  will  be  given  only  scant  attention  in  this  connection. 

Ancient  History. — During  the  classic  era  of  Grecian  literature. 
Homer  in  his  "Odyssey"  ^  caused  Helen  of  Troy  to  put  some  drug  into 
wine  to  "lull  all  pain  and  anger,  and  bring  forgetfulness  of  every  sor- 
row." It  is  not  known  what  constituted  Helen's  nepenthe,  some  believ- 
ing it  to  have  been  mandragora,  while  others  maintain  it  was  opium. 

Five  hundred  years  after  Homer,  Herodotus,  the  great  historian  of 
Greece,  tells  of  a  custom  among  Scythians  of  inhaling  the  fumes  of  a  vari- 
ety of  hemp,  which  produced  an  exalted  mental  state,  followed  by  sleep. 

The  chronicles  of  ancient  Eome  furnish  similar  evidence.  For  in- 
stance, these  record  the  utterances  of  the  renowned  mythological  oracle 
of  Apollo  at  Delphi,  which  were  probably  nothing  more  nor  less  than  the 
exaggerated  ravings  of  the  priestess  Pythea.  Her  seemingly  inspired 
sayings  are  attributed  to  the  inhalation  of  carbon  dioxid,"  which  is  sup- 
posed to  have  been  generated  in  the  cavern.  Having  been  removed  to  the 
altar  before  the  convulsive  stage  set  in,  her  mumblings  were  interpreted 
by  the  faithful  as  the  voice  of  Apollo.  The  famous  Grotta  del  Cane,  near 
Naples,  at  the  present  time  furnishes  an  example  of  conditions  which 
may  have  been  utilized  for  just  such  purposes.^ 

■  Beginning  of  the  Christian  Era. — That  the  use  of  mandragora  was 
well  known  at  the  beginning  of  the  Christian  era  is  absolutely  certain, 
for  many  references  to  it  are  made  by  the  writers  of  that  period.  Dios- 
corides,  a  Greek  physician,  who  lived  about  the  middle  of  the  first  cen- 
tury, and  who  was  for  seventeen  hundred  years  an  authority  on  the 
science  of  healing,  makes  what  is  probably  the  earliest  allusion  to  its 
use.'*  Galen,^  another  Greek  and  a  contemporary  of  Dioscoridcs,  makes 
mention  of  the  power  of  mandragora  to  paralyze  sensation  and  motion. 
Lucian,  in  speaking  of  Demosthenes,  says  he  aroused  his  fellow  citizens, 

^Homer's  "Odyssey";    4,  220. 

^Memphis  marble  and  vinegar  were  used  as  a  local  anesthetic  by  the  Eomans! 

*  From  the  sides  of  the  cavern,  steam  and  carbon  dioxid  emanate  in  suffi- 
cient quantities  to  form  a  stratum  in  which  dogs  are  first  convulsed  and  then 
asphyxiated,  while  persons  who  are  in  a  standing  position  above  the  stratum 
are  unaffected. 

*  Be  Med.  Mat.,  Lib.  4,  76.  The  root  of  ' '  atropa  mandragora ' '  was  boiled 
in  wine  and  administered  prior  to  surgical  operations, 

=  lUd.,  Lib.  7,  207. 


THE    HISTORY    OF    ANESTHESIA  3 

who  were  as  if  put  to  sleep  by  mandragora.  Roman  historians,  among 
tliem  Pliny/  also  described  the  use  of  mandragora  from  earliest  times. 
The  people  of  their  country  employed  it  extensively  to  relieve  the  suffer- 
ing of  victims  of  crucifixion. 

Asiatic  Sources. — Preparations  of  different  drugs  were  made  by  the 
Jews  and  Chinese,  and  given  to  criminals  to  produce  such  a  mental  state 
that  they  would  confess  their  crimes,  or  to  make  less  agonizing  the  hor- 
rible tortures  inflicted. 

In  view  of  the  fact  that  it  is  indigenous  to  China,  undoubtedly  the 
Chinese  were  the  first  to  use  Indian  hemp  as  a  means  of  dulling  the  con- 
sciousness of  pain.  The  Egyptians  used  this  herb  under  the  name  of 
"liasliish"  The  fumes  of  this,  when  inhaled,  induced  intoxication  and 
mental  exaltation. 

A  Chinese  practitioner  of  the  third  century,  Hoa-tho,  gave  to  a 
patient  a  preparation  of  hemp,  whereby  he  shortly  became  insensible  "as 
if  he  had  been  drunk  or  deprived  of  life."  We  are  told  that  after  a  cer- 
tain number  of  days  the  patient  found  himself  "reestablished"  without 
having  experienced  the  slightest  pain  during  the  operation. 

The  ancients  early  noted  that  volatile  substances  acted  more  promptly 
and  effectually  when  inhaled  than  other  substances  taken  by  the  mouth, 
and  inhalation  was  employed  by  the  Greeks,  Eomans,  Arabians  and 
Chinese. 

Middle  Ages. — In  the  thirteenth  century,  an  oil  which  put  patients 
to  sleep  on  occasions  of  painful  operations  was  prepared  and  successfully 
used  by  Hugo  de  LucCa.  It  consisted  "of  opium,  of  the  juice  of  the 
unripe  mulberry,  of  hyoscyamus,  of  the  juice  of  hemlock,  of  the  juice  of 
the  leaves  of  mandragora,  of  the  juice  of  the  leaves  of  wood  ivy,  of  lettuce 
seeds,  of  dock  seeds,  and  water  hemlock  boiled  with  a  sponge,  which, 'for 
use,  was  soaked  in  hot  water  and  applied  to  the  nostril."  To  awaken  the 
patient,  another  sponge,  soaked  in  vinegar,  was  applied  to  the  nose. 

As  late  as  1534  this  "spongia  somnifera"  was  still  in  use.  Shortly 
after  this.  Pare  referred  to  it  as  a  practice  "used  formerly  by  operators." 
The  uncertain  action  of  this  concoction  arising  from  necessary  differ- 
ences in  preparation,  from  the  method  of  application  of  the  vapor,  and 
from  the  ignorance  of  the  strength  of  the  various  ingredients,  led  to  its 
temporary  abandonment.  It  is  difficult  to  imagine  why  the  preparation 
of  anesthetics  was  neglected,  when  medicine  was  making  the  rapid 
progress  which  marked  its  development  during  the  sixteenth  century. 

Hewitt  ^  states :  "In  1589  Giambattista  Porta,  a  surgeon  who  prac- 
ticed in  Naples,  used  an  essence  made  from  hyoscyamus,  solanum,  poppy, 
and  belladonna,  enclosed  in  a  leaden  vessel,  and,  the  lid  being  opened,  the 
patient  would  draw  in  by  breathing  the  most  subtle  strength  of  the 

'  Be  Med.  Mai.,  Lib.  35,  94. 

^Hewitt,  Frederick  D.:     "Anaesthetics,"  4tli  ed.,  3, 


4  ANESTHESIA 

vapor,  so  that  thereby  he  would  be  buried  in  a  most  profound  sleep,  nor 
be  aware  of  what  had  been  done  to  him." 

Shakespeare  makes  several  references  to  the  soporific  effects  of  vari- 
ous drugs,  showing  that  a  knowledge  of  this  quality  obtained  in  his  day. 
Early  in  the  seventeenth  century,  he  makes  Cornelius,  the  court  physi- 
cian, prescribe  a  drug  which 

"Will  stupefy  and  dull  the  sense  awhile;  but  there  is 
No  danger  in  what  show  of  death  it  makes, 
More  than  the  locking  up  the  spirits  a  time, 
To  be  more  fresh,  reviving. " 

It  is  thus  seen  that  ancient,  medieval  and  modern  history  furnish 
numerous  examples  of  the  use  of  drugs  and  other  media  which  brought 
about  partial  or  complete  unconsciousness.  Moreover,  it  is  well  estab- 
lished that  the  Assyrians  accomplished  the  same  end  by  the  compression 
of  blood  vessels  before  circumcision;  and  in  the  early  part  of  the  seven- 
teenth century  this  custom  was  revived  by  Valverdi,  who  compressed  the 
nerves  and  blood  vessels  of  the  parts  to  be  operated  upon. 

Hypnotism. — The  foregoing  resume  of  historical  references  to 
methods  employed  in  former  times  needs  but  the  addition  of  a  brief  men- 
tion of  the  hypnotic  effects  induced  by  weird  incantations,  as  practiced 
by  the  Egyptians,  Persians,  Indians,  and  others.  This  leads  up  to  the 
time  of  Greatrakes,  the  noted  "Irish  stroker,"  who  produced  sleep  as  a 
result  of  his  magnetic  touch,  or  "the  laying  on  of  hands."  He  was  prob- 
ably the  most  noted  advocate  of  this  method  prior  to  Mesmer,  the  Swiss 
physician,  who,  about  the  middle  of  the  eighteenth  century,  investigated 
the  phenomena  of  animal  magnetism  along  scientific  lines,  applying  his 
researches  to  curative  ends  and  enunciating  a  doctrine  which  became 
known  as  "mesmerism,"  after  the  founder. 

Real  Beginnings  of  Surgical  Anesthesia. — It  was  at  the  close  of  the 
eighteenth  century  that  modern  surgical  anesthesia  was  foreshadowed, 
with  the  discovery  of  hydrogen  in  1766,  nitrogen  in  1772,  and  oxygen 
and  nitrous  oxid  in  1774.  "Pneumatic  chemistry,"  as  it  were,  opened 
up  a  field  of  experimentation  which  made  possible  surgical  operations 
under  conditions  which  Humphrey  Davy  described  as  "uneasiness  being 
swallowed  for  a  few  minutes  by  pleasure." 

Soon  after  the  discovery  of  these  gases,  attempts  were  made  to  put 
them  to  practical  use.  In  1785  Pierson,  of  Birmingham,  England,  used 
ether  inhalation  for  asthma,  and  in  1789  the  Medical  Pneumatic  Insti- 
tute was  organized  under  Dr.  Beddoes,  where  huge  reservoirs  of  gases 
were  installed  for  the  treatment  of  phthisis  and  other  diseases  by  inhala- 
tion. This  Institute,  which  was  superintended  by  Humphrey  Davy, 
while  not  successful  in  itself,  was  important  in  that  it  led  to  Davy's 
experiments  with  nitrous  oxid.     By  1799  and  1800  Davy  had  become 


THE    HISTORY    OF    ANESTHESIA  5 

sufficiently  well  acquainted  with  this  gas  to  use  it  for  the  alleviation  of 
headache  and  also  for  the  extraction  of  one  of  his  own  wisdom  teeth. 
This  latter  event  led  him  to  make  the  historic  prediction,  "Since  nitrous 
oxid  seems  capable  of  destroying  physical  pain,  it  may  be  used  in  surgical 
operations,  where  there  is  no  great  effusion  of  blood."  The  value  of  this 
suggestion  was  not  recognized  for  nearly  half  a  century. 

Warren,  of  Boston,  used  "sulphuric  ether"  in  1805  on  a  patient  suffer- 
ing with  phthisis,  and  in  1806  it  was  used  in  attacks  of  asthma.  Faraday 
seems  to  have  been  the  first  to  recognize  the  value  of  "sulphuric  ether" 
as  an  anesthetic.  In  1818,  there  appeared  a  paragraph  attributed  to 
Faraday  in  the  Quarterly  Journal  of  Science  and  Arts,  in  which  it  was 
pointed  out  that  "when  the  vapor  of  ether  is  mixed  with  common  air 
and  inhaled,  it  produces  effects  very  similar  to  those  occasioned  by 
nitrous  oxid." 

An  incident  occurred  on  November  6,  1821,  which,  had  it  been  cor- 
rectly interpreted,  might  have  led  to  an  earlier  discovery  of  general 
anesthesia.  On  that  day.  Stockman,  of  Utica,  gave  an  exhibition  in 
Eome,  N.  Y.,  of  the  effects  of  nitrous  oxid.  After  the  demonstration,  the 
lecturer,  on  adjourning  to  a  back  room,  found  there  a  young  man  com- 
pletely anesthetized  with  his  mouth  to  the  faucet  of  the  gas  tank.  He 
had  been  stealing  the  gas  for  its  exhilarating  effect  and  had  been  over- 
come by  it. 

The  first  successful  experiments  upon  lower  animals,  for  the  purpose 
of  rendering  them  insensible  to  pain  by  means  of  the  inhalation  of  gases, 
were  made  by  Henry  Hill  Hickman  ^  between  the  years  of  1820  and  1828. 
Hickman  was  twenty  years  of  age  when  he  became  a  member  of  the 
Eoyal  College  of  Surgeons  and  began  his  career  as  a  country  practitioner 
in  the  little  town  of  Ludlow,  Shropshire,  England. 

"Impressed  by  the  agonizing  sufferings  of  those  on  whom  he  was 
called  to  operate,  he  resolved  to  seek  some  method  of  alleviating  their 
pain  by  rendering  them  unconscious  before  the  operation.  With  this 
object,  he  commenced  a  series  of  experiments  on  animals,  first,  by  pro- 
ducing semi-asphyxiation  by  the  exclusion  of  atmospheric  air;  then  by 
causing  them  to  inhale  small  quantities  of  carbon  dioxid,  and  later 
nitrous  oxid  gas.  After  rendering  the  animals  unconscious,  he  excised 
the  ears,  amputated  their  legs,  made  incisions,  then  dressed  the  wounds, 
noted  the  time  they  took  to  heal,  and  the  period  of  their  complete  recov- 
ery. He  carried  on  these  experiments  for  some  time,  and  at  last  met 
with  considerable  success.  This  convinced  him  that,  could  he  but  carry 
out  his  experiments  on  the  human  subject,  his  methods  would  become  of 
the  greatest  value  to  mankind  in  making  painless  the  performance  of 
major  surgical  operations." 

'  Henry  Hill  Hickman :  "A  Forgotten  Pioneer  of  Anesthesia, ' '  Brit.  Med. 
J.,  April  13,  1912,  843. 


6 


ANESTHESIA 


His  notes  on  some  of  these  interesting  experiments  are  still  extant 
in  his  own  handwriting,  of  which  the  following  is  an  extract: 

"Experiment  1,  March  20th. — I  took  a  puj^py  a  month  old  and 
placed  it  on  a  piece  of  wood  surrounded  by  water,  over  which  I  put  a 
glass  cover  so  as  to  prevent  the  access  of  atmospheric  air ;  in  ten  minutes 
he  showed  great  marks  of  uneasiness,  in  twelve  minutes  respiration  be- 
came difficult,  and  in  seventeen  minutes  ceased  altogether;   at  eighteen 

minutes  I  took  off  one  of  the 
ears,  which  was  not  followed  by 
hemorrhage ;  respiration  soon 
returned,  and  the  animal  did 
not  appear  to  be  the  least  sensi- 
ble of  pain;  in  three  days  the 
ear  was  perfectly  healed. 

"Experiment  2. — Four  days 
after,  the  same  puppy  was  ex- 
posed to  a  decomposition  of  the 
carbonate  of  lime  by  sulphuric 
acid.  In  one  minute  respira- 
tion ceased;  I  cut  off  the  other 
ear,  which  was  followed  by  very 
trifling  hemorrhage,  and,  as  be- 
fore, the  puppy  did  not  appear 
to  suffer  any  pain;  in  four  days 
the  wound  healed,.  The  day 
after  the  operation  he  seemed 
to  require  an  additional  quan- 
tity of  food,  which  induced  me 
to  weigh  him,  and  I  found  he  gained  9  oz.,  1  drachm  and  24  grains  in 
nine  days." 

While  Hickman  was  successful,  he  was  unable  to  demonstrate  "the 
results  of  his  experiments  before  his  professional  brethren,  and  every- 
where he  was  met  with  the  greatest  scepticism  and  his  system  was  gen- 
erally derided  and  condemned  as  dangerous  and  useless.  .  .  .  Dis- 
heartened by  his  failure  to  secure  a  hearing  from  the  profession  in  his 
own  country,  he  at  length  resolved  to  lay  the  matter  before  the  Eoyal 
Academy  of  Medicine  in  Paris,  and  drew  up  a  memorial  to  King  Charles 
X.  praying  for  permission  to  perform  his  experiments  before  the  leading 
medical  men  of  that  city."  The  king  sent  the  letter  to  the  Eoyal  Acad- 
emy of  Medicine  and  notified  Hickman.  The  Academy  appointed 
Gerardin  ^  to  investigate  the  matter  and  report  to  them.  He  reported  as 
follows  on  October  21,  1828 : 

"Painless  Operations. — M.  Gerardin  reported  on  a  letter  written  to 
^  Grerardin :     Archives  generales,  Paris,  18,  453. 


Fig.  1. — Henky  Hill  Hickman. 


THE    HISTORY    OF    ANESTHESIA  7 

His  Majesty  Charles  X.  by  Mr.  Hickman,  a  London  surgeon,  in  which 
that  gentleman  asserted  he  had  discovered  a  means  of  performing  the 
most  troublesome  and  dangerous  operations  without  pain.  The  method 
consisted  in  producing  temporary  insensibility  l)y  the  methodical  intro- 
duction of  certain  vapors  into  the  lungs.  Mr.  Hickman  had  made 
numerous  experiments  on  animals,  and  was  desirous  of  obtaining  the 
cooperation  of  the  leading  physicians  and  surgeons  of  Paris,  in  order  to 
make  the  same  experiments  on  the  human  subject." 

French  surgeons  proved  to  be  no  more  liberal  in  their  attitude  than 
had  been  their  British  colleagues.  When  Gerardin's  report  was  presented 
only  one  member  (Larry)  championed  Hickman's  cause,  offering  himself 
as  a  subject  for  experimentation.  The  other  members  sneered  at  the 
idea  proposed  by  Hickman,  and  so  the  young  surgeon,  disappointed  and 
hopeless,  returned  to  England,  where  he  died  a  few  months  later  (1829) 
at  the  age  of  twenty-nine. 

"In  this  tragic  manner  the  curtain  fell  upon  the  life  of  Henry  Hill 
Hickman,  who  practically  sacrificed  his  career  and  gave  his  life  in  his 
attempts  to  gain  recognition  for  his  discovery  of  a  method  of  producing 
anesthesia  by  inhalation  and  rendering  patients  unconscious  to  pain  dur- 
ing severe  surgical  operations." 

While  the  suggestion  of  painless  surgery  seemed  to  be  in  the  air, 
no  one  laid  definite  hold  upon  it.  In  1830,  two  deaths  from  nitrous 
oxid  attracted  much  attention.  Each  was  caused  by  the  breaking 
of  a  jar  containing  the  gas  in  the  room  where  the  victim  was 
sleeping. 

Discovery  of  Ether  Anesthesia. — The  efforts  of  the  past  culminated 
in  the  discovery  of  inhalation  anesthesia,  with  ethyl  ether  as  the  agent, 
in  1842.  The  public  had  gradually  become  familiar  with  the  inhaling 
of  vapors.  It  is  reported  in  the  Americaii  Journal  of  Science  for  Janu- 
ary, 1832,  that  Ives,  of  New  Haven,  used  chloroform  (see  page  281)  in 
medicine.  Humphrey's  book  on  "Medicated  Vapors"  appeared  in  1831. 
At  about  this  time  scientific  lecturers  were  in  the  habit  of  demonstrating 
the  intoxicating  properties  of  ether  on  young  men ;  and  many  young  peo- 
ple, especially  medical  students,  held  wild  frolics  under  its  influence,  after 
inhaling  it  to  the  point  of  intoxication.  It  so  happened  that  these  lec- 
tures and  ether  parties  were  directly  responsible  for  the  discovery  of 
surgical  anesthesia. 

In  1839,  some  young  people  held  a  quilting  party  near  Athens,  Ga., 
after  which  they  finished  the  evening  by  inhaling  ether.  At  the  height 
of  the  frolic,  a  negro  boy  appeared  at  the  door  and  was  invited  to  partake 
of  the  ether,  but  he  refused.  Some  of  the  boys  dragged  him  in 
and  forced  a  handkerchief,  covered  with  ether,  to  his  mouth  and  nose. 
After  a  long  struggle  he  became  quiet  and  the  boys  desisted.  Instead 
of  getting  up,  the  negro  lay  as  if  asleep  and,  much  to  the  terror  of 


8  ANESTHESIA 

the  culprits,  did  not  awaken  until  medical  attention  was  given  an  hour 
later. 

The  inhalation  of  ether  and  also  nitrous  oxid  to  the  stage  of  excite- 
ment was  a  common  occurrence  in  different  parts  of  the  country  at  this 
time. 

It  remained  for   Crawford  W.   Long/   of   Georgia,   to  intelligently 

^  Crawford  Williamson  Long  was  born  in  Daniellsville,  Madison  County, 
Georgia,  November  1,  1815.  His  family  was  prominent  socially  and  in  public 
affairs.  Long  graduated  second  in  his  class  from  Franklin  College  at  the  age 
of  nineteen,  and  from  the  medical  department  of  the  University  of  Pennsyl- 
vania in  1839,  after  which  time  he  spent  one  year  "walking"  the  hospitals  of 
New  York  City.  As  a  student  in  the  University  of  Pennsylvania  he  was  under 
the  immediate  tutorship  of  George  B.  Wood.  Da  Costa  ("Crawford  W.  Long," 
"Old  Penn  WeeMy  Beview,  April  6,  1912)  states:  "Wood's  condemna- 
tion of  the  premature  reporting  of  cases  and  drug  actions  may  have  decided 
Long  a  few  years  later  to  delay  in  publishing  the  report  of  the  action  of  ether. 
He  insisted  that  observers  must  never  be  content  with  a  single  experiment. ' ' 
Woods  Hutchinson  stated  at  the  unveiling  of  the  monument  to  Long  at  Jeffer- 
son, Georgia,  that  "His  discovery  was  no  accident.  His  real  genius  and  the 
proof  of  his  greatness  lay  in  his  wisdom  to  see  the  possibilities.  His  courage 
to  attempt  experiments,  the  confidence  in  his  own  opinions,  and  the  heartfelt 
love  and  sympathy  for  his  suffering  patients  led  him  to  employ  the  anesthetic 
he  had  discovered  not  once  but  many  times.  He  was  great  in  his  courage,  brav- 
ing the  possibility  of  the  fearful  consequences  which  would  have  followed  failure 
in  those  early  days  of  experiment.  In  many  matters  he  was  ahead  of  his  day 
and  generation.  He  was  one  of  the  first  to  hold  that  tuberculosis  is  curable, 
and  that  fresh  air  and  diet  will  effect  cures  in  this  dread  malady.  He  added 
to  the  sum  of  human  immunity  from  horror  and  suffering  long  before  Sir  J.  Y. 
Simpson   used   chloroform  for  the  purpose. ' ' 

Jackson,  in  a  letter  to  the  Bost.  Med.  and  Surg.  J.,  April  11,  1861,  states, 
among  other  things,  that,  "I  then  called  on  Profs.  Joseph  and  John  Le 
Conte,  then  of  the  University  of  Georgia,  at  Athens,  and  inquired  if  they  knew 
Dr.  Long,  and  what  his  character  was  for  truth  and  veracity.  They  both  as- 
sured me  that  they  knew  him  well,  and  that  no  one  who  knew  him  in  that  town 
would  doubt  his  word,  and  that  he  was  an  honorable  man  in  all  respects.  .  .  . 
He  is  a  very  modest,  retiring  man  and  not  disposed  to  bring  his  claims  before 
'any  but  a  medical  or  scientific  tribunal. ' ' 

The  University  of  Pennsylvania,  on  March  30,  1912,  unveiled  a  medallion  to 
Long.  The  state  of  Georgia  has  sent  his  name  to  Washington,  D.  C,  as  one  of 
her  two  most  celebrated  sons.  Hewitt,  Foy,  and  Buxton,  of  England,  as  well  as 
Young,  of  Johns  Hopkins  Hospital,  all  give  the  credit  to  Long  as  the  dis- 
coverer of  surgical  anesthesia. 

J.  P.  Groves,  in  a  letter  to  Hugh  H.  Young,  of  Johns  Hopkins  Hospital, 
under  date  of  .January  15,  1897,  in  giving  an  account  of  an  operation,  states  the 
following :  ' '  The  patient  was  placed  in  a  recumbent  position  on  a  bed,  with 
the  hand  to  be  operated  on  in  front  for  convenience  of  the  surgeon.  Dr.  Long 
poured  ether  on  a  towel,  and  held  it  to  the  patient's  nose  and  mouth,  too,  to 
get  the  benefit  of  inhalation  from  both  sources.  Dr.  Long  determined  when  the 
patient  was  sufficiently  etherized  to  begin  the  operation  by  pinching  or  pricking 
him  with  a  pin.  Believing  that  no  harm  would  come  of  its  use  for  a  con- 
siderable length  of  time,  he  profoundly  anesthetized  the  patient,  then  gave  me 


THE    HISTORY    OF    ANESTHESIA 


make  use  of  facts  which  were  common  knowledge  to  all.  Long  and  his 
pupils  indulged  frequently  in  "ether  frolics,"  during  which  he  was  badly 
bruised,  yet  he  noticed,  upon  recovery,  that  he  had  not  been  conscious  of 
pain.  Frequent  observations  of  this  fact,  in  connection  with  himself 
and  his  students,  led  Long  to  conceive  the  idea  of  using  ether  to  prevent 
the  pain  of  surgical  oj)erations. 

When  twenty-six  years  of  age,  and  in  the  first  year  of  his  practice, 
Long  determined  to  try  the  ex- 
periment with  ether  as  soon  as 
possible,  and  so,  on  March  30, 
1843,  he  administered  ether  to 
Mr.  James  Venable  and  re- 
moved a  small  tumor  from  the 
neck.  At  the  close  of  the  oper- 
ation the  patient  assured  Long 
that  he  had  not  experienced 
even  the  slightest  degree  of 
pain. 

This  experiment  was  so 
highly  successful  that  Long 
continued  to  administer  ether 
in  surgical  cases,  recording 
about  eight  such  cases  between 
1842  and  1845.  But  since  his 
was  the  narrow  sphere  of  a  lo- 
cal country  doctor,  his  surgical 
cases  were  few  and  his  fame  did 
not  get  beyond  the  restricted 
world  in  which  he  lived.  He 
made  no  secret  of  his  discovery, 
but  did  not  advertise  the  fact  until  others  had  laid  claim  to  the  honor. ^ 

the  towel,  and  I  kept  up  the  influence  by  holding  it  still  to  the  patient 's  nose. 
The  patient  was  entirely  unconscious — no  struggling — patient  passive  in  the 
hands  of   the  operator. ' ' 

^  The  original  bill  for  services  of  Long  to  Mr.  Venable  is  still  in  existence,  and 
is  as  follows: 

James   Venable 

to  Dr.  C.  W.  Long,  Dr. 


Fig.  2. — Crawford  W.  Long. 


1842. 

Jan. 

Mch. 

May 

June 


28  Sulphuric    Ether     $    .25 

30  Sulphuric  Ether  and   Exsecting  tumor 2.00 

13  Sul.    Ether    25 

6  Exsecting    tumor    2 .  00 


$4.50 


10  ANESTHESIA 

Long  not  only  used  ether  upon  patients,  but  behind  closed  doors  he 
administered  it  to  a  medical  student,  and  had  the  student  adminis- 
ter the  anesthetic  to  him,  in  order  to  discover  the  physiological  ac- 
tion of  the  drug.  Owing  to  the  prejudice  and  ignorance  of  the  popu- 
lace, Long  was  prevented  from  using  ether  in  as  many  cases  as  he  might 
have.  In  a  very  scientific  spirit  he  administered  ether  to  a  negro  boy 
having  two  fingers  to  be  amputated,  removing  one  finger  under  the  in- 
fluence of  ether  and  the  second  without  ether.  He  did  this  to  prove 
that  insensibility  to  pain  was  due  to  the  agent  used. 

"Dr.  Long  is  necessarily  deprived  of  the  larger  honor  which  would 
have  been  his  due  had  he  not  delayed  years  after  the  universal  acceptance 
of  surgical  anesthesia.  It  is  also  to  be  regretted  that  his  published  details 
of  the  mode  of  administering  the  ether  and  the  depth  of  the  anesthesia 
are  so  meager  and  unsatisfactory.  While  the  accepted  rule  that  scientific 
discovery  dates  from  publication  is  a  wise  one,  we  need  not  in  this  in- 
stance withhold  from  Dr.  Long  the  credit  of  independent  and  prior 
experiment  and  discovery,  but  we  cannot  assign  to  him  any  influence 
upon  the  historical  development  of  our  knowledge  of  surgical  anesthesia, 
or  any  share  in  the  introduction  to  the  world  at  large  of  the  blessings  of 
this  matchless  discovery."  ^ 

In  regard  to  this  point,  DaCosta  -  remarks :  "Long  has  been  criti- 
cised for  not  publishing  his  discovery  at  once.  Jenner  waited  twenty 
years  to  publish  his  and  after  twenty  years  had  only  made  twenty-three 
observations.  Suppose  someone  had  published  about  vaccination  after 
Jenner  had  worked  nineteen  years,  would  Jenner  any  the  less  have  been 
the  discoverer?" 

But  being  far  removed  from  the  turmoil  and  strife  that  environed  the 
lives  of  the  then  three  other  claimants,  Long  was  not  embittered  as  were 
the  others.  He  continued  to  practice  medicine  in  Jackson  County, 
Georgia,  and  died  June  16,  1878,  in  the  sixty-second  year  of  his  a,ge. 

The  Discovery  of  Nitrous  Oxid  for  Surgical  Anesthesia. — In  1844, 
two  years  and  eight  months  after  Long  anesthetized  the  first  patient  with 
ether,  Horace  Wells,^  a  dentist  of  Hartford,  Conn.,  attended  a  lecture  on 
"Laughing  Gas"  by  G.  Q.  Colton,  a  chemist.  He  noticed  (as  had  Long 
with  ether)  that  a  young  man  under  the  influence  of  nitrous  oxid 
bruised  himself  very  severely,  yet  was  apparently  unconscious  of  pain. 
Wells  had  long  been  studying  the  question  of  the  painless  extraction  of 
teeth,  and  had  previously  reasoned  that,  if  excitement  from  ordinary 
causes  could  make  one  indifferent  to  pain,  the  same  would  probably  be 
true  of  artificial  excitement. 

^ Welch,   William    H. :      "A    Consideration    of    the    Introduction    of    Surgical 
Anesthesia, ' '  9. 
^  Loc.  cit. 
^Horace  Wells  was  born  in  Hartford,  Windsor  Co.,  Vt.,  Jan.  21,  1815. 


THE    HISTORY    OF    ANESTHESIA 


11 


This  incident  impressed  upon  him  the  l)elief  tliat  the  administration  of 
nitrous  oxid  would  bring  about  the  result  for  whicb  be  bad  been  looking. 
He  planned  to  test  his  conclusions  oji  himself.  The  next  day,  December 
11,  1844,  Colton  was  called  in  to  administer  the  gas,  and,  while  Wells  was 
under  its  influence,  Riggs  extracted  one  of  his  teeth.  On  recovering 
consciousness.  Wells  was  so  en- 
thusiastic over  the  success  of  the 
operation  that  he  made  plans 
for  its  immediate  use,  and  there- 
after daily  extracted  teeth  under 
its  influence.  Early  in  1845,  he 
went  to  Boston  in  order  to  lay 
the  matter  before  the  hiedical 
profession.  He  gave  a  public 
demonstration  before  the  Har- 
vard Medical  College,  but  be- 
cause he  did  not  understand 
the  proper  administration  of 
the  gas — probably  because  he 
did  not  use  a  sufficient  volume 
—  the  demonstration  failed. 
Wells  was  a  sensitive  man,  and 
this  public  failure  overwhelmed 
him  and  he  felt  himself  dis- 
graced. He  continued  to  ad- 
minister gas  in  private  practice 
for  some  time,  but  eventually 
gave  up  dentistry  altogether. 
In  1847  his  reason  gave  way  and,  early  in  1848,  he  died  by  his  own  hand. 


Fig.  3. — Horace  Wells. 


ETHER 


On  witnessing  one  of  Wells'  operations,  H.  0.  Marcy  remarked  that 
as  a  student  he  had  found  that  nitrous  oxid  and  the  vapor  of  "sulphuric 
ether,"  when  inhaled,  produced  exactly  the  same  effects.  Wells  had  tried 
ether,  but,  owing  to  the  choking  sensations  jDroduced,  resolved  to  adhere 
to  nitrous  oxid. 

Morton. — It  was  left,  however,  to  William  T.  G.  Morton,  a  former 
pupil  of  Wells,  to  place  the  use  of  ether  as  an  anesthetic  upon  a  sound 
basis.  His  discovery  was  entirely  independent  of  that  of  Long,  who  had 
preceded  him  four  years.^ 

^"William  Thomas  Greene  Morton  (Patton,  J.  M. :  ''Anesthesia  and  Anes- 
thetics,"  17)    was  born   in  Massachusetts,   studied   dentistry   in   Baltimore,    and 


12 


ANESTHESIA 


First   Public    Demonstration. — The    first    public    demonstration    of 
surgery  without  pain  was  given  in  the  Massachusetts  General  Hospital, 

was  a  successful  practitioner  in  Boston.  He  experimented  with  drugs  and  with 
hypnotism  in  con"neetion  with  the  painless  extraction  of  teeth,  and,  as  we  have 
seen,  was  associated  with  Wells  in  his  investigations  of  nitrous  oxid.  After 
the  public  failure  of  the  experiment  of  Wells,  he  abandoned  gas  and  tried 
'chloric  ether'  with  unsatisfactory  results.     At  the  suggestion  of  his  preceptor, 

Charles  Jackson  (Morton  being  at 
that  time  a  student  of  medicine), 
a  physician  of  Boston,  but  best 
known  as  a  geologist  and  chemist, 
he  experimented  with  sulphuric 
ether,  beginning  his  experiments 
on  animals. ' '  In  connection  with 
his  experiments  upon  animals  Mor- 
ton 's  wife  writes :  ' '  Every  spare 
hour  he  could  get  was  spent  in  ex- 
periment. He  used  to  make  experi- 
ments nearly  every  day  on  '  Nig, '  a 
black  water  spaniel,  a  good-sized 
dog  that  had  belonged  to  his  fa- 
ther. His  clothes  seemed  always 
saturated  with  the  smell  of  ether. 
One  day  he  came  running  into  the 
house  in  great  distress  (for  he 
was  always  tender-hearted),  lead- 
ing the  dog,  which  walked  rather 
queerly,  and  said,  'Poor  Nig,  I 
have  had  him  asleep  a  long  time; 
I  was  afraid  I  had  killed  him.'  " 
Morton  stated  to  his  wife,  ' '  The 
time  will  come,  my  dear,  when  I 
will  banish  pain  from  the  world. ' ' 
' '  At  this  time  he  used  to  bottle  up 
all  sorts  of  queer  bugs  and  insects  until,  the  house  was  full  of  crawling  things.  He 
would  administer  ether  to  all  of  these  little  creatures  and  especially  to  the  big 
green  worms  he  found  on  grapevines. ' '  His  friends  laughed  at  these  experiments, 
but  Morton  replied,  "I  shall  succeed.  There  must  be  some  way  of  deadening 
pain. ' '     It  was  after  this  that  he  began  experimenting  upon  himself. 

"His  success  in  this  direction  encouraged  him  to  make  a  personal  experiment, 
and,  in  September,  1846,  he  inhaled  ether  from  a  handkerchief  while  sitting  in 
his  operating  chair.  He  was  unconscious  for  several  minutes,  and,  on  regain- 
ing consciousness,  he  was  so  elated  by  his  success  that  he  decided  to  again  in- 
hale the  drug  and  submit  to  an  extraction  while  under  its  influence.  At  this 
moment  the  door  bell  rang  and  he  admitted  a  man  named  Eben  Frost,  whose 
face  was  bandaged  and  who  was  in  that  state  of  mingled  hope  and  consterna- 
tion so  familiar  to  all  dental  surgeons.  He  asked  if  it  were  not  possible  to 
mesmerize  him,  and  readily  consented  to  inhale  ether  when  assured  that  it  was 
superior  to  mesmerism.  To  the  joy  of  the  operator  and  the  astonishment  of  the 
patient,  the  attempt  was  perfectly  successful."  Elizabeth  Morton:  "The  Dis- 
covery of  Anesthesia,"  McClure's  Magazine,  Sept.,  1896. 


£ 

^ 

, 

i 

i 

Wf 

f 

I 

^ 

s. 

^^^ 

"J'^'^ 

m 

Fig.  4. — William  T.  G.  Mf)HTON. 


THE    HISTORY    OF    ANESTHESIA 


13 


in  the  presence  of  the  surgical  and  medical  stall;  in  the  c:rowded 
amphitheater,  on  October  16,  1846.  "Sulphuric  ether"  was  used  on  this 
occasion,  though  Warren  used  "chloric  ether"  ^  thereafter,  and  pre- 
ferred it. 

"It  was  a  trying  moment  to  this  medical  student  when  he  determined 
to  exhibit  his  discovery  of  practical  ether  anesthesia  before  his  class- 
mates, professors,  and  the  public.  But  so  convinced  was  he,  by  reason 
of  his  experience  gained  in  private  practice,  of  success,  that  he  was  will- 


FiG.  5. — The  Original  Mohton  Inhaler. 


ing  to  face  this  ordeal.  Morton  came  into  the  amphitheater  late,  delayed 
by  waiting  for  the  completion  of  a  new  inhaler.  Just  a  few  minutes 
before.  Dr.  Warren  had  remarked,  'As  Dr.  Morton  has  not  arrived,  I 
presume  he  is  otherwise  engaged,'  apparently  conveying  the  idea  that 
Dr.  Morton  was  not  likely  to  appear.  As  he  was  about  to  proceed  with 
his  operation  Morton  entered.  Amidst  that  sea  of  faces  he  saAv  not  one 
which  was  sympathizing.  Blank  incredulity,  or,  at  the  best,  curiosity, 
alone  was  to  be  seen.  Warren,  turning  to  him,  remarked:  'Well,  sir, 
your  patient  is  ready.'  Adjusting  his  apparatus,  Morton  calmly  admin- 
istered the  anesthetic  and,  turning  to  Dr.  Warren,  said :  'Dr.  Warren, 
your  patient  is  ready.'  The  silence  of  the  tomb  reigned  in  the  large 
amphitheater  while  Dr.  Warren  made  his  first  incision  through  the  skin 
and  dissected  out  a  large  tumor,  while  the  patient  made  no  sign  nor 
moved  a  miiscle  of  his  body.  When  the  operation  was  completed.  Dr. 
Warren  turned  to  the  audience  and  said  slowly  and  emphatically :    'Gen- 

^See  Baskerville  and  Hamor:     J.  Ind.  Eng.  Chem.,  4,  No.  3. 


14 


ANESTHESIA 


tlemen,  this  is  no  humbug,'  and  Bigelow  remarked,  'I  have  seen  some- 
thing to-day  that  will  go  around  the  world.' "  ^ 

Operations  under  ether  followed  quickly,  and  from  that  time  its  use 
as  an  anesthetic  sj^read  rapidly  throughout  the  world. 

It  is  almost  inconceivable  to 
those  who  now  witness  operations 
daily  under  anesthesia  to  appreciate 
what  it  really  means  to  the  patient 
and  to  those  who  are  compelled  to 
be  present.  No  one  has  brought  this 
out  more  forcibly  than  Hayden,^  in 
an  article  in  which  he  gives  a 
description  of  an  operation  previous 

'  In  July,  1868,  Morton  left  his  home 
for  New  York  to  reply  to  an  article  that 
had  recently  appeared  in  one  of  the 
monthlies  advocating  Jackson's  claim  to 
be  the  discoverer  of  ether  anesthesia. 
His  wife  states  that  this  article  "agi- 
tated him  to  an  extent  she  had  never 
seen  before. ' '  It  was  extremely  hot,  and 
after  reaching  New  York  he  telegraphed 
his  wife  that  he  was  ill  and  for  her  to 
come.  Under  the  treatment  of  the  dis- 
tinguished Sayre,  Morton  rapidly  im- 
proved and  he  attempted  to  drive  his 
wife  to  a  hotel  on  Washington  Heights 
as  a  change  from  the  hot  city.  On  the 
way  through  Central  Park  he  complained 
of  feeling  sleepy,  but  refused  to  give 
his  wife  the  reins  or  to  turn  back.  Sud- 
denly he  sprang  from  the  carriage  and 
stood  on  the  ground,  apparently  in  great 
distress.  He  quickly  lost  consciousness, 
and  his  wife  called  upon  a  policeman 
and  Swann,  a  druggist,  who  assisted  in 
placing  Morton  upon  the  grass,  but  he 
was  past  hope  of  recovery.  He  was 
taken  at  once  to  St.  Luke 's  Hospital,  but 
was  dead  by  the  time  he  reached  there. 
At  the  time  of  his  death  he  was  forty- 
eight  years  of  age.  He  was  buried  in  Mount  Auburn  Cemetery  in  Boston  in  the 
presence  of  many  noted  physicians.  Over  his  tomb  an  inscription  written  by 
Jacob  Bigelow  is  placed,  which  states: 

"William  T.  G.  Morton,  Inventor  and  Eevealer  of  anesthetic  inhala- 
tion, by  whom  pain  in  surgery  was  averted  and  annulled;  before  whom, 
in  all  times,   surgery  was   agony;    since   whom,   science  has   control   of 


Fig.  6. — The  Original  Morton  Inhaler. 


pain. 
'Hayden,  William  E. : 


Inter.  J.  Surg.,  1896. 


THE    HISTORY    OF    ANESTHESIA  15 

to  the  introduction  of  an<3sthesia,  and  of  operations  as  they  arc  conducted 
at  this  time. 

"With  a  meek,  imploring  look,  and  the  startled  air  of  a  fawn,  as  her 
modest  gaze  meets  the  bold  eyes  fixed  upon  her,  she  is  brought  into  the 
amphitheater  crowded  with  men,  anxious  to  see  the  shedding  of  her 
blood,  and  laid  upon  the  table.     With  a  knowledge  and  merciful  regard 


Fig.  7. — One  of  the  Earliest  Operations  under  Ether  at  the  Massachusetts 

General  Hospital. 

as  to  the  intensity  of  the  agony  which  she  is  to  suffer,  opiates  and  stimu- 
lants have  been  freely  given  her,  which,  perhaps,  at  this  last  stage,  are 
again  repeated.  She  is  cheered  by  kind  words  and  the  information  that 
it  will  soon  be  over,  and  she  freed  forever  from  what  now  afflicts  her; 
she  is  enjoined  to  be  calm,  and  to  keep  quiet  and  still,  and,  with  assis- 
tance at  hand  to  hold  her  struggling  form,  the  operation  is  commenced. 
"But  of  what  avail  are  all  her  attempts  at  fortitude?  At  the  first 
clear,  crisp  cut  of  the  scalpel,  agonizing  screams  burst  from  her,  and, 
with  convulsive  struggles,  she  endeavors  to  leap  from  the  table.  But 
force  is  nigh.  Strong  men  throw  themselves  upon  her  and  pinion  her 
limbs.  Shrieks  upon  shrieks  make  their  horrible  way  into  the  stillness 
of  the  room,  until  the  heart  of  the  boldest  sinks  in  his  bosom,  like  a  lump 
of  lead. 


16  ANESTHESIA 

"At  length  it  is  finished,  and,  prostrate  with  pain,  weak  from  her 
exertions,  and  bruised  by  the  violence  used,  she  is  borne  from  the  amphi- 
theater to  her  bed  in  the  wards,  to  recover  from  the  shock  by  slow 
degrees." 

Now 

"How  would  the  same  case  be  now?  With  a  sweet,  calm  smile  play- 
ing around  her  mouth, — an  evidence  of  pleasant  dreams, — her  eyes  fast 
closed  as  in  a  gentle  sleep;  her  body  extended  languidly  and  listlessly 
as  in  the  repose  of  childhood,  surrounded  by  no  ill-favored  men  whose 
powerful  aid  will  be  needed;  with  no  crowd  of  medical  men  to  guard 
against  unforeseen  accidents.  The  surgeon,  and  his  two  assistants  to 
pass  the  necessary  implements,  or  to  assist  in  stanching  the  blood,  are 
all  who  are  required.  At  his  leisure — not  hurried  by  the  demands'  of 
pain  to  complete  as  soon  as  possible — he  can  coolly  prosecute  his  work, 
varying  it  to  suit  any  exigency  of  the  occasion,  and  ready  to  profit  by 
any  favorable  contingency  which  its  course  may  present. 

"When  finished,  and  all  is  in  that  proper  condition  which  will  demand 
no  fresh  interference  for  some  time,  the  patient  is  awakened  from  her 
slumber,  and  receives  the  glad  information  that  it  is  all  over,  and  she  is 
to  be  tortured  no  more.  The  one  grateful  look  which  answers  this  news 
can  have  no  value  placed  upon  it.  Alone,  it  is  worth  a  lifetime  of  exer- 
tion and  trouble." 

The  formal  announcement  to  the  medical  profession  of  this  discovery 
was  made  by  H.  J.  Bigelow  ^  in  a  paper  read  before  the  Academy  of 
Arts  and  Sciences,  on  November  3rd,  and  before  the  Boston  Society  of 
Medical  Improvement,  on  November  9  th,  and  published  in  the  Boston 
Medical  and  Surgical  Journal,  November  18,  1846.^ 

Letheon. — On  October  27,  1846,  Morton  and  Jackson  sought  to 
patent  their  anesthetic  under  the  name  of  "Letheon."  From  its  odor 
it  was  soon  recognized  as  "sulphuric  ether."  ^    Not  long  afterwards  Jack- 

^  Bigelow  {Boston  Med.  and  Surg.  J.,  Nov.  18,  1846)  called  attention  to  the 
experiments  which  he  conducted  for  the  purpose  of  ascertaining  the  nature  of 
"Letheon."  His  first  experiment  was  with  sulphuric  ether,  the  odor  of  which 
was  easily  detected  in  Morton 's  preparation. 

-Patton,  Joseph  M. :     "Anesthesia  and  Anesthetics,"  18. 

^  J.  F.  B.  Flagg,  M.D.,  D.D.S.,  one-time  Professor  of  Anatomy  and  Physi- 
ology in  the  Philadelphia  College  of  Dentistry,  "was  particularly  prominent  as 
having  announced  to  the  dental  and  medical  world  that  the  so-called  'Letheon' 
of  Mr.  Morton,  of  Boston,  was  simply  washed  sulphuric  ether,  thus  securing  to 
them  an  unpatentable  material."     Med.  and  Surg.  Reporter,  Phil.,  Dec.  7,  1872. 

Flagg  (Flagg,  J.  F.  B.:  "Ether  and  Chloroform,"  Phila.,  1851),  in  re- 
viewing briefly  the  history  of  the  inhalation  of  ether,  says:  "The  surgeons  of 
Massachusetts  General  Hospital,  together  with  a  few  initiated,  become  aston- 
ishingly fervent  in  their  praises  of  an  'Invention,'  which  required  the  com- 
bined  efforts   of   scientific   attainments   and   mechanical   skill   to    develop.      Clas- 


THE    HISTORY    OF    ANESTHESIA 


17 


son  resigned  his  interest  in  the  "invention"  and  attempted  to  show  that 
he  alone  was  the  discoverer  of  anesthesia  by  ether.  While  he  was  writing 
his  contentions  to  the  French 
Institute,  Horace  Wells  went  in 
person  to  claim  the  honor  of  be- 
ing the  real  discoverer  of  anes- 
thesia, and  thus  a  three-sided 
controversy  was  begun. 

"Partly  with  a  view  of  keep- 
ing his  discovery  out  of  the 
hands  of  persons  who  might  use 
it  unwisely,  and  acting  upon  the 
advice  of  Eufus  Choate  and  Ca- 
leb Gushing,  lawyers  of  national 
reputation,  Dr.  Morton  patent- 
ed his  application  of  sulphuric 
ether."  ^ 

While  Morton  probably  had 
the  right  to  patent  his  discov- 
ery, the  fact  that  he  did  so  was 
most  regrettable,  for  the  patent 
right  caused  much  dissatisfac- 
tion and  adverse  comment. 
Many  refused  to  accept  it  on  the 
grounds  of  quackery.    One  year 

after  its  discovery,  1847,  one  of  the  largest  hospitals  in  North  America 
had  not  tried  it  at  all.  When  Europe  confirmed  the  efficacy  of  ether,  the 
opposition  subsided. 

sieal  erudition  came  to  their  aid,  and,  for  a  season,  good,  old  'sulphuric  ether' 
was  made  to  succumb  to  the  name  of  'letheon. ' 

"A  circular  is  broadly  cast  through  the  length  and  breadth  of  the  country, 
announcing  that  a  compound  has  been  discovered,  which,  by  breathing  into  the 
lungs,  induces  so  deep  a  slumber  as  to  enable  us  to  perform  the  most  painful 
surgical  operations  with  entire  unconsciousness  on  the  part  of  the  patient.  In 
connection  with  this  announcement  are  the  names  of  Dr.  Jackson  and  Dr.  Mor- 
ton, as  its  combined   (?)   discoverers. 

"A  patent  is  sought,  and,  under  the  protection  of  a  caveat,  agents  are  ap- 
pointed to  traverse  the  country,  selling  to  all,  who  will  buy,  the  right  to  use 
the  compound.  Thus  qualifying  everybody  and  anybody  in  the  use  of  this 
powerful  agent  that  would  pay  the  sum  of 

"In  cities  over  150,000  inhabitants,  $200  for  seven  years. 

"In  cities  over  50,000  and  less  than   150,000,  $150   for  seven   years. 

"And  so  on,  down  to 

"In  cities  under  5,000,  $37  for  seven  years." 

^  Morton,  Mrs.  Elizabeth  Whitman :  ' '  The  Discovery  of  Anesthesia, ' '  Mc- 
Clure's  Magazine,  Sept.,   1896. 


Fig.  8. — ^Charles  T.  Jackson. 


18  ANESTHESIA 

In  1849  Morton  petitioned  Congress  for  a  reward  for  his  discovery. 
He  was  at  once  opposed  by  Jackson  and  the  friends  of  Wells,  who  was 
then  dead.  The  celebrated  ether  controversy  thus  begun  occupied 
the  attention  of  Congress  for  many  years,  and  was  characterized 
by  the  greatest  animosity  between  these  former  bosom  friends  and  com- 
panions. 

Jackson's  name  is  most  closely  associated  with  his  claim  to  priority 
in  the  discovery  of  the  anesthetic  properties  of  ether,  which  M^as  the  sub- 
ject of  a  long  controversy,  that  was  very  painful  to  him.  His  claim 
was  supported  by  the  testimony  of  Francis  Alger,  J.  B.  S.  Jackson, 
Martin  Gray,  and  T.  T.  Bouve,  to  whose  eulogy  before  the  Boston  Society 
of  Natural  History  we  are  indebted  for  most  of  the  facts  given  here- 
with. These  gentlemen  were  his  chosen  friends,  and  were  for  a  long 
time  closely  associated  with  him.  J.  B.  S.  Jackson  was  one  of  the  signers 
of  a  remonstrance  addressed  to  Congress  against  its  making  a  grant  of 
money  to  W.  G.  Morton,  Jackson's  rival  in  the  claim  of  discovery,  based 
upon  the  ground  that  the  signers  believed  that  the  reward,  so  far  as  the 
question  of  discovery  was  concerned,  ought  to  go  to  Jackson.  Martin 
Gray  published  a  pamphlet  under  his  own  name,  maintaining  that  Jack- 
son was  the  sole  discoverer  of  anesthesia,  and  that  Morton  could  only  be 
considered  to  have  performed  a  secondary  part  by  proving  that  the  ad- 
ministration of  ether  is  safe  in  surgical  operations.  Bouve,  who  was  for 
a  considerable  time  a  student  in  Jackson's  laboratory,  and  afterward  met 
him  frequently  in  social  intercourse,  accorded  to  him  the  honor  of  having 
been  the  discoverer  of  the  anesthetic  properties  of  ether,  but  "never 
thought  him  entitled  to  the  credit  of  its  introduction  into  use,  or  even 
to  that  of  having  thoroughly  verified  what  he  claimed  to  be  true  respect- 
ing the  safety  of  administering  it.  He  had  experimented  upon  himself, 
and  had  afterward  demonstrated  respecting  it,  even  going  so  far  as  to 
recommend  its  use  by  others,  and  this  constituted  discovery ;  bvit  he  did 
not  prove  to  others  what  he  was  himself  convinced  of,  and  allowed 
precious  time  to  pass — yes,  much  time — without  making  any  application 
of  the  discovery.  Indeed,  had  it  not  been  that  Mr.  Morton  sought  from 
him  means  to  prevent  pain  when  extracting  teeth,  it  is  doubtful  if  the 
world  would  have  had  the  advantage  of  the  discovery  for  years,  if  ever. 
The  truth  is.  Dr.  Jackson  was  a  great  genius  and  had  remarkable  intui- 
tive perceptions  of  scientific  truths,  but,  from  some  peculiarities  hard  to 
comprehend,  he  often  contented  himself  with  enunciating  what  he  recog- 
nized as  fact,  without  striving  to  substantiate  it.  He  himself  admitted 
his  shortcomings  in  this  respect.  When  Dr.  Gray  had  written  his  essay 
upon  the  discovery  of  ether,  claiming  for  Dr.  Jackson  all  the  merits  of 
its  introduction,  I  objected  to  his  view  of  the  matter,  and  took  the 
ground  that  the  world  was  indebted  to  both  Jackson  and  Morton  for  the 
great  boon ;  to  one  as  the  scientific  discoverer  and  suggester  of  its  use  in 


THE    HISTORY    OF    ANESTHESIA  19 

surgical  operations,  to  the  other  for  his  application  of  it  and  its  practical 
introduction. 

"Dr.  Jackson,  learning  of  this,  upon  meeting  me  remarked  that  I  was 
thought  not  to  be  friendly  to  him  in  the  matter.  I  then  said :  'Doctor, 
you  have  known  for  a  long  period  what  Mr.  Morton  is  now  demonstrating 
to  be  true,  but  have  allowed  it  to  remain  a  dormant  fact  in  your  mind. 
If  he  had  not  sought  information  from  you,  might  it  not  have  remained 
so  for  some  years  longer?'  He  answered  that  possibly  it  might.  I  think 
it  may  fairly  be  said  that  without  both  Jackson  and  Morton  the  world 
might  have  been  none  the  happier  for  what  either  would  have  done ;  one 
supplemented  the  other.  To  them  together  belongs  the  great  honor  of 
having  served  humanity  beyond  what  language  can  express."  ^ 

'Tor  five  years  Long  refused  to  take  part  in  the  conflict,  but  finally, 
in  1854,  persuaded  by  his  friends  that  in  that  way  alone  could  he  obtain 
recognition  of  his  claims,  he  wrote  to  Senator  Dawson  giving  an  account 
of  his  work.  It  seems  that  Dawson  was  a  friend  of  Jackson,  for  he  wrote 
to  him  of  this  new  claimant  and  requested  him  to  investigate  his  case. 
This  Jackson  did,  calling  upon  Long  at  his  home  in  Athens  on  March  8, 
1854. 

"Dr.  Jackson  finally  acknowledged  the  justice  of  Dr.  Long's  claims 
and  wrote  to  Senator  Dawson  to  that  effect. 

"On  April  15,  1854,  the  appropriation  bill  ^  was  up  before  the  Senate 
for  its  final  reading.  The  friends  of  Wells  and  Morton,  relying  on  the 
volumes  of  manuscript  they  had  presented,  were  confidently  awaiting  the 
result,  when  Senator  Dawson  arose  and  said  that  he  had  a  letter  from 
Jackson  which  acknowledged  that  a  Dr.  Long  in  Georgia  had  undoubt- 
edly used  ether  before  any  of  the  claimants  for  the  appropriation. 

"Coming  as  it  did  from  so  prominent  a  contestant,  this  announce- 
ment fell  like  a  thunderbolt  on  the  rival  claimants,  and  from  that  time 
they  seem  to  have  lost  all  hope  of  gaining  the  reward,  and  passively 
allowed  the  bill  to  die. 

"Desirous  only  of  preventing  another  from  being  recognized  by  Con- 
gress as  the  discoverer,  and  not  wishing  any  pecuniary  reward  himself. 
Long  never  pushed  the  matter  farther,  and  his  documents  of  proof  were 
never  even  brought  up  before  Congress."  ^ 

Anesthesia  in  England. — Bigelow  took  some  ether  with  him  to  Lon- 
don and  the  first  operation  (extraction  of  a  tooth)  was  performed  on 
December  19,  1846,  at  the  home  of  Bott,  of  Gower  Street.*     Two  days 

"^Pop.  Sci.  Mon.,  1881,  19,  405. 

"  The  bill  proposed  to  appropriate  $100,000  as  a  recompense  to  the  real  dis- 
coverer. 

^  Young,  Hugh  H. :  "Long,  the  Discoverer  of  Anesthesia,"  read  before  the 
Johns  Hopkins  Hospital  Historical  Society,  Nov.  8,  1896. 

*A  very  interesting  account  of  the  first  major  operation  under  ether  in  Eu- 
rope is  given  by  Dr.  F.  W.  Cock  in  the   University  College  Hospital  Magazine, 


20  .  ANESTHESIA 

later,  ether  was  administered  to  patients  at  the  University  College  Hos- 
pital by  Squires,  Liston  operating.  In  1847,  J.  Y.  Simpson,  a  Scottish 
physician,  first  used  ether  in  midwifery,  and,  finding  that  the  pains  of 
labor  might  be  wholly  abolished  without  interfering  with  uterine  con- 
tractions, adopted  it  in  his  obstetric  practice. 

CHLOROFORM 

On  March  8,  1847,  Flourens  pointed  out  the  anesthetic  qualities  of 
chloroform  and  ethyl  chlorid,  but  his  observations  did  not  attract  gen- 
eral attention.  During  the  same  year  Simpson,^  who  had  not  been 
entirely  satisfied  with  ether  on  account  of  its  irritating  qualities,  incon- 
venience of  administration  and  odor,  consulted  Waldie,  a  chemist  of 
Liverpool.  The  latter  suggested  the  use  of  chloroform,  of  which  "chloric 
ether"  was  an  alcoholic  solution.  The  vapor  of  "chloric  ether"  had  been 
previously  used  as  an  anesthetic  with  little  success,  but  when  Simpson 
had  obtained  the  chloroform  from  Edinburgh  and  experimented  with  it, 
on  November  4,  1847,  he  was  more  than  satisfied  with  its  anesthetic 
qualities.    Thereafter  he  tried  it  in  obstetric  practice  with  success.^ 

as  follows :  ' '  Dr.  Bott,  a  general  practitioner  of  Gower  Street,  W.  C,  informed 
Eobert  Liston,  the  surgeon  of  University  College  Hospital,  or  rather  North  Lon- 
don Hospital,  as  it  was  then  called,  that  he  had  used  ether  successfully  on  a 
dental  case  in  his  own  house.  Liston  sought  the  aid  of  Peter  Squire,  the  well 
known  chemist  of  Oxford  Street,  in  order  to  fashion  an  apparatus  for  adminis- 
tering ether,  and  the  inhaler  was  first  tried  on  his  nephew,  William  Squire. 
The  latter,  profiting  by  the  experience  on  himself,  gave  the  anesthetic  to  Liston 's 
patient.  The  patient  was  a  man  of  thirty- six  years  suffering  from  disorganized 
knee-joint,  and  it  was  decided  to  amputate.  The  mouthpiece  was  applied  by 
Squire  and  the  patient  soon  sank  into  insensibility.  William  Cadge,  Liston 's 
junior,  compressed  the  femoral  artery,  and  Eansome,  the  house  surgeon,  held  the 
limb.  Liston  rapidly  completed  the  operation  in  twenty-five  seconds,  accord- 
ing to  Palmer,  the  dresser.  The  inhalation  had  been  stopped  as  the  operation 
was  begun.  On  coming  round,  the  patient  tried  to  lift  himself,  and  asked  when 
the  operation  was  going  to  begin.  On  being  shown  the  stump  he  fell  back  and 
wept.  Liston.  acknowledged  the  success  of  the  new  anesthetic  by  the  remark, 
'  The-  Yankee  dodge,  gentlemen,  beats  mesmerism  hollow. '  This  was  a  sarcastic 
hit  at  Dr.  Elliotson,  a  physician  of  the  same  hospital,  who  practiced  the  occult 
art  in  connection  with  medicine.  The  notes  of  this  ease  are  still  extant.  The 
dresser,  who  wrote  them,  remarks  that  not  the  slightest  groan  was  heard  from 
the  patient,  nor  was  his  countenance   at  all  expressive  of  pain. ' ' 

^  J.  Y.  Simpson  was  born  at  Bathgate,  Linlithgowshire,  Scotland,  June  7,  1811. 
In  1832  he  received  the  degree  of  Doctor  of  Medicine.  On  Nov.  4,  1847,  he  dis- 
covered the  anesthetic  properties  of  chloroform,  and  made  known  the  fact  in  a 
paper  on  Nov.  10,  1847.  He  received  the  highest  honors  from  the  British  Gov- 
ernment for  this  discovery.  He  died  at  Edinburgh,  Scotland,  May  6,  1870,  in  the 
fifty-ninth  year  of  his  life. 

-Simpson,  Sir  James:  "New  Anaesthetic,"  1847,  7;  Illustrated  London 
News,  Dec.  4,  1847,  370-2.     Simpson,  E.  B.,  Century,  25,  412;  Liv.  Age,  66,  720; 


THE    HISTORY    OF    ANESTHESIA 


21 


On  November  10,  1847,  the  slow  but  steady  progress  of  the  use  of 
ether  received  an  effectual  setback  by  the  publication  of  Simpson's 
famous  pamphlet  on  a  "New  Anaesthetic  Agent  as  a  Substitute  for  Sul- 
phuric Ether  in  Surgery  and  Midwifery." 

Because  of  Simpson's  writing  and  his  efforts  in  behalf  of  chloroform, 
the  use  of  this  new  anesthetic  spread  with  remarkable  activity,  and  soon 
had     almost     entirely     supplanted  _ 

ether  in  general  surgery.  Its  prog- 
ress was  hastened  also  by  its  ease  of 
management  and  speedy  action,  and 
because  its  vapor  was  much  pleas- 
anter  to  take  than  that  of  ether. 

Theological  Opposition  to  the 
TJse  of  Anesthetics. — One  of  the 
most  singular  struggles  of  medical 
science  during  modern  times  oc- 
curred in  our  own  days  and  in  a 
Protestant  country.  Just  as  there 
residted  a  theological  and  sectarian 
condemnation  of  and  opposition  to 
inoculation,  vaccination,  and  the  use 
of  coca  and  quinin,  so  did  the  ad- 
vocacy of  the  use  of  anesthetics  in 
obstetrical  cases  by  James  Young 
Simpson  meet  with  a  vigorous  storm 
of  protest.  The  hostility  of  the 
Scotch  ecclesiastical  authorities  to 
the  alleviation  of  pain  in  childbirth 

had  its  source  in  an  old  belief  in  Scotland.  In  1591,  for  example,  a  lady 
of  rank,  one  Euf  ame  Macalyane,  was  charged  with  seeking  the  assistance 
of  Agnes  Sampson  for  the  relief  of  pain  at  the  time  of  the  birth  of  her 
two  sons,  and  was  accordingly  burned  alive  on  the  Castle  Hill  of  Edin- 
burgh ;  ^  and  this  view,  which  stood  for  nothing  kind,  merciful,  or  hu- 
mane, persisted  even  to  the  middle  of  the  nineteenth  century.  Simpson's 
use  of  chloroform  was  denounced  from  the  pulpit  as  impious  and  contrary 
to  Holy  Writ;  and  Biblical  texts  were  numerously  cited,  the  general 
declaration  being  that  to  use  chloroform  was  "to  avoid  one  part  of  the 
primeval  curse  on  women."  As  in  the  time  of  witchcraft,  so  strong  was 
the  power  of  the  church,  so  universal  the  belief  in  the  guilt  of  all  women, 
that,  notwithstanding  the  fact  that  Simpson  wrote  pamphlet  after  pam- 

Mon.  J.  Med.  Sci.,  Sept.,  1847;  Ednb.  Medico-CMr.  Soc,  Nov.  11,  1848.  J.  T. 
Simpson's  "Anaesthesia,"  1849,  93,  145,  182,  193,  203.  Chloroform  of  the 
density  1.48  was  used  by  Simpson  in  1847. 

'Dalyell's  "Darker  Superstitions  of  Scotland,"  130,  133. 


Fig.  9. — Sir  James  Y.  Simpson.  "To 
whose  genius  and  benevolence  the 
world  owes  the  blessings  derived  from 
the  use  of  chloroform  for  the  relief  of 
suffering." 


22 


ANESTHESIA 


phlet  to  defend  the  blessing  he  had  introduced,  he  seemed  about  to  be 
overcome,  when  he  seized  a  new  weapon,  which  was,  according  to  White,^ 
probably  the  most  absurd  by  which  a  great  cause  was  ever  won:  "My 
opponents  forg-et,"  he  said,  "the  twenty-first  verse  of  the  second  chapter 
of  Genesis;  it  is  the  record  of  the  first  surgical  operation  ever  per- 
formed, and  that  text  proves  that 
the  Maker  of  the  universe,  before 
He  took  the  rib  from  Adam's  side 
for  the  creation  of  Eve,  caused  a 
deep  sleep  to  fall  upon  Adam."  We 
are  told  that  this  was  a  stunning 
blow,  but  that  it  did  not  entirely 
kill  the  sectarian  opposition,  for  the 
leaders  of  the  resistance  had 
strength  left  to  maintain  that  the 
"deep  sleep  of  Adam  took  place  be- 
fore the  introduction  of  pain  into 
the  world — in  a  state  of  innocence." 
However,  Thomas  Chalmers,  a  new 
champion,  now  intervened,  and, 
with  a  few  pungent  remarks,  dis- 
persed the  enemy  forever,  and  the 
greatest  victory  of  science  against 
sufi^ering  was  gained.^ 

When  anesthetics  were  first  used 
in  obstetrics  in  the  United  States, 
prominent  New  England  clergymen  also  assailed  their  administrators  as 
having  sacrilegiously  thwarted  "the  curse,"  but  such  "impious  frustra- 
tion of  the  curse  of  the  Almighty  upon  woman"  ^  began  to  be  regarded 
as  the  greatest  boon  ever  conferred  by  science  upon  mankind,  shortly 
after  the  vigorous  support  of  Chalmers  in  Scotland. 

The  Early  Use  of  Chloroform  in  Midwifery. — The  records  of  the 
Dublin  Lying-in  Hospital  show  that  the  mortality  with  anesthesia  was 
one  in  three  hundred  and  twenty,  and  that  the  women  were  delivered 
within  two  hours  from  the  commencement  of  labor.  Without  anesthesia, 
the  average  labor  case  was  twenty  hours  with  a  mortality  of  one  in  eleven. 
Some  Physicians  Believe  in  Pain. — In  spite  of  these  statistics,  we 
find  some  doctors  pleading  earnestly  against  anesthesia  in  those  days. 
"Pain  during  operations  is  in  a  majority  of  cases  even  desirable,  and  its 
prevention   or   annihilation   is,   for   the   most   part,   hazardous   to    the 

^"A  History  of  the  Warfare  of  Science  with  Theology,"  1908,  2,  63. 
=  Duns'  "Life  of  Sir  J.  Y.  Simpson,"  1873,  215-222;  256-260. 
^  For  the  views  of  an  enlightened  woman  on  this  question,  see  Matilda  Joslyn 
Gage's  "Woman,  Church  and  State,"  241,  242,  244  and  433. 


Fig.  10. — Bust  of  Sir  James  Y.  iSimpsoh. 
(In  the  National  Gallery,  Edinburgh, 
Scotland.) 


THE    HISTORY    OF    ANESTHESIA  23 

patient."  A  French  physiologist  stated  that  it  was  a  trivial  matter  to 
suffer,  and  a  discovery  whose  object  was  to  prevent  pain  was  of  a  slight 
interest  only. 

Prejudice  Developed  against  Chloroform. — Until  January  28,  1848, 
chloroform  was  believed  to  be  a  safe  anesthetic,  but  the  death  of  a  young 
woman  on  that  day,  while  under  the  influence  of  chloroform,  and  several 
other  deaths  not  long  after,  gave  good  cause  for  the  suspicion  that  the 
drug  might  be  more  dangerous  than  at  first  supposed. 

Scientific  Administration  of  Ether  and  Chloroform. — John  Snow, 
believing  that  in  a  too  concentrated  vapor  of  chloroform  lay  the  danger, 
invented  an  inhaler  in  1847  which  was  designed  to  regulate  the  per- 
centage of  vapor.  After  several  years  of  experience  with  anesthetics,  he 
published,  in  1858,  as  the  result  of  his  experiments,  the  first  attempt  to 
place  the  administration  of  ether  and  chloroform  upon  a  scientific  basis. 
He  was  the  first  to  describe  the  effect  of  inhaling  definite  percentages 
of  chloroform  vapor  and  air,  and  experimented  to  discover  the  manner 
in  which  death  occurred  under  chloroform,  ether,  and  other  anesthetics. 
He  came  to  the  conclusion  that  chloroform  caused  death  by  primary 
cardiac  paralysis,  due  to  the  inhalation  of  a  too  concentrated  vapor. 

Efforts  to  Overcome  Objections  to  Chloroform  by  Use  of  Substitutes 
and  Improved  Inhalers. — Because  of  his  belief  in  the  dangers  of  chloro- 
form, Snow  investigated  amylene'^  as  an  anesthetic  and  was  the  first  to 
administer  it.  His  death  checked  considerably  the  advance  in  the  scien- 
tific investigation  of  anesthetic  agents. 

J.  T.  Clover,  a  worthy  successor  of  Snow,  was  the  first  to  improve  the 
principle  of  chloroform  administration.  He  published,  in  1862,  an 
account  of  his  chloroform  inhaler,  by  means  of  which  the  percentages 
of  chloroform  and  air  could  be  more  accurately  regulated  than 
hitherto. 

"A.C.E.  Mixture." — The  agitation  of  the  question  of  the  physiologi- 
cal effects  of  anesthetics  caused  an  investigation  to  be  made  by  a  Com- 
mittee of  the  Eoyal  Medical  and  Chirurgical  Society  of  Great  Britain. 
This  Committee,  appointed  "to  inquire  into  the  uses  and  the  physiologi- 
cal, therapeutical,  and  toxicological  effects  of  chloroform,"  reported  in 
1864.  They  agreed  with  Snow  that  the  concentrated  vapor  of  chloro- 
form was  dangerous,  and,  because  of  the  inconvenience  of  the  adminis- 
tration of  ether,  recommended  the  "A.C.E.  mixture"  as  a  substitute. 
This  was  originally  used  by  George  Harley  and  was  composed  of  alcohol, 
one  part,  chloroform,  two  parts,  and  ether,  three  parts.  The  committee 
also  urged  the  free  admixture  of  air  as  of  first  importance.  A  detailed 
account  of  this  and  other  mixtures  will  be  found  in  Chapter  XX,  p.  688. 

Substitutes. — Two  or  three  new  anesthetics  were  introduced  about 
this  time,  but  while  they  may  have  been  favorably  received  in  certain 

'  See  Chap.  XX,  p.  698. 


24  ANESTHESIA 

circles,  and  for  a  limited  period  of  time,  they  never  gained  general  favor. 
In  1861,  "Kerosolene"  was  introduced  in  Boston  by  Dickinson,  Bow- 
ditch,  and  Merrill.  In  1867,  Benjamin  Eichardson  introduced  "bichlorid 
of  methylene.".  For  a  time  many  surgeons  were  very  enthusiastic  over 
the  drug,  claiming  that  it  had  fewer  drawbacks  than  any  other.  Amer- 
ican surgeons  were  not  so  enthusiastic,  believing  that  its  dangers  differed 
only  in  degree  from  those  of  chloroform. 

First  Vapor  Inhaler. — On  November  30,  1867,  in  an  article  in  the 
Medical  Times  and  Gazette,  Junker  described  a  very  ingenious  appar- 
atus for  the  administration  of  chloroform,  especially  valuable  in  opera- 
tions on  the  nose,  throat,  or  mouth. 

Nitrous  Oxid  More  Generally  Appreciated. — For  nearly  twenty 
years  little  was  heard  of  nitrous  oxid,  but  in  1863,  because  of  the  efforts 
of  the  same  Colton  from  whom  Wells  had  received  his  first  inspiration, 
nitrous  oxid  began  to  regain  the  ground  it  had  lost. 

In  that  year,  Colton  formed  an  association  of  dentists  to  perform 
operations  with  the  use  of  nitrous  oxid,  and  by  1867  had  recorded 
20,000  administrations  without  an  accident.  These  results  strongly 
attracted  the  dental  profession.  Eymer,  of  London,  administered  the 
gas  successfully  there  in  1864,  and  in  1867  Colton  demonstrated  in 
Paris  before  Evans,  an  American  dentist.  This  led  to  its  general  intro- 
duction into  England,  for,  during  the  following- year,  Colton  had  his 
own  apparatus  taken  to  that  country  by  Evans,  who  administered  the 
gas  before  the  Dental  Hospital  of  London.  On  Dec.  7,  1868,  a  joint 
committee  of  the  Odontological  Society  and  the  Dental  Hospital  issued 
a  report  which  favored  nitrous  oxid  so  highly  that  it  has  since  held 
the  highest  position  among  the  anesthetics  of  modern  dentistry.  The 
analgesic  properties  of  nitrous  oxid  in  dentistry  are  of  recent  develop- 
ment. 

Nitrous  Oxid  and  Oxyg'en. — In  1870,  Colton  published  a  pamphlet 
showing  the  result  of  the  physiological  action  of  the  gas  in  its  practical 
application  to  the  original  discoveries  of  Davy,  Wells,  and  others.  A 
long  step  toward  making  nitrous  oxid  more  practicable  was  taken  in 
1868,  when  E.  Andrews,  of  Chicago,  reported  for  the  first  time  the  use 
of  a  mixture  of  nitrous  oxid  and  oxygen  with  most  satisfactory  results. 
He  published  accounts  of  several  cases,  in  which,  by  mixing  oxygen  with 
nitrous  oxid,  he  had  obtained  a  more  satisfactory  form  of  anesthesia 
than  with  nitrous  oxid  alone.  But  since  the  medical  profession  had 
always  insisted  on  the  exclusion  of  air,  Andrews  failed  to  get  the  notice 
he  deserved.  The  late  Paul  Bert,  ten  years  afterwards,  again  drew 
attention  to  the  same  procedure. 

In  order  to  overcome  its  too  feeble  action,  the  large  amount  of  gas 
necessary,  and  the  limited  time  during  which  anesthesia  could  be  pro- 
duced, Bert  gave  a  mixture  of  nitrous  oxid  and  oxygen  (85: 15)  under 


THE    HISTORY    OF    ANESTHESIA  25 

increased  atmospheric  pressure.  He  argued  that  the  pressure  was 
necessary  in  order  to  have  a  uniform  mixture  of  the  gases,  but 
Hewitt  and  others  believed  that  pressure  was  not  essential.  Bert's 
apparatus  for  positive  pressure  was  tried  with  only  partial  success,  it 
being  too  cumbersome  and  expensive.  Hewitt  states  that  the  most 
recent  and  best  development  in  modern  anesthetics  is  the  combination  of 
oxygen  with  nitrous  oxid,  producing  a  non-asphyxial  and  absolutely 
safe  form  of  anesthesia. 

Discarding  Chloroform  for  Ether. — During  the  year  1870  Simpson 
wrote  to  Bigelow  in  Boston:  "Chloroform  is  the  greatest  triumph  of 
all,  for  it  has,  if  not  entirely,  yet  nearly  entirely,  superseded  the  use  of 
'sulphuric  ether.' "  In  spite  of  this  statement,  the  use  of  ether  had,  in 
the  main,  held  its  position  against  chloroform  in  the  United  States.  In 
1890,  after  twenty  years  filled  with  records  of  accidents  from  the  use  of 
chloroform,  surgeons  all  over  the  world  began  to  discard  it  for  ether. 

Improved  Methods  for  Administering  Ether. — Pollack,  Warrington, 
and  Hayward  warned  against  the  use  of  chloroform,  and  Clover's  experi- 
ments did  not  lead  him  to  the  belief  that  chloroform  could  be  made  as 
safe  as  ether.  He  became  less  and  less  inclined  to  use  it,  substituting 
nitrous  oxid  in  minor  operations.  He  improved  the  methods  for  ad- 
ministering the  latter  gas  and  introduced  its  use  as  a  preliminary  to 
ether.  Clover  also  discovered  the  proper  principles  of  ether  adminis- 
tration, and  pointed  out  the  advantages  of  air  limitation  during  the 
etherization.  In  1876,  he  published  an  account  of  his  apparatus  for 
the  administration  of  nitrous  oxid  and  ether,  either  separately  or  in 
succession. 

Warmed  Ether  Vapor. — The  introduction  of  Clover's  portable  regu- 
lating ether  inhaler  in  1877  went  a  long  way  toward  solving  the  question 
of  the  rapid  and  safe  administration  of  ether.  This  inhaler  has  gained 
a  wider  reputation  than  any  other  apparatus  of  its  kind.  Its  use  has 
shown  the  value  of  warmed  ether  vapor  with  regard  to  after-effects. 

Chloroform  Condemned. — During  this  year,  1877,  Clover  adopted 
"bichlorid  of  ethidene"  (ethylidene  chlorid),  which  Snow  had  used 
in  1851;  but,  since  a  death  resulted  from  it,  it  did  not  gain  favor.  The 
report  of  the  "Glasgow  Committee"  of  the  British  Medical  Association, 
issued  in  1879,  agreed  with  Snow  and  his  followers  in  stating  that  blood 
pressure  and  heart  action  under  chloroform  were  distinctly  reduced; 
and  while,  where  fatalities  occurred,  respiration  usually  ceased  first, 
the  heart  might  be  primarily  paralyzed.  The  report  of  the  First  Medical 
Association  Committee,  issued  in  1880,  stated  that  many  deaths  from 
chloroform  were  clearly  proven  to  be  the  result  of  carelessness  or  igno- 
rance. Chloroform  was  condemned  and  ether  also,  though  in  a  less 
marked  degree.  The  committee  recommended  "bichlorid  of  ethidene," 
but  this  drug  is  now  practically  unknown. 


26  ANESTHESIA 

The  dispute  reached  such  proportions  that,  in  order  to  settle  it,  the 
Hyderabad  Chloroform  Commission  was  appointed  in  1889.  This  was 
financed  by  the  Nizam  of  Hyderabad  at  the  suggestion  of  Surgeon- 
Major  Lawrie,  whose  views  had  long  been  with  the  Edinburgh  School. 
After  numerous  experiments,  the  commission  filed  a  report  agreeing 
entirely  with  Syme  and  the  supporters  of  chloroform.  The  conclusions 
thus  stated  were  not  accepted  by  the  medical  profession  generally,  and 
so  a  second  Hyderabad  Commission  was  appointed,  the  Mzam  again 
supplying  the  funds.  This  time  experiments  were  carried  on  upon  a 
larger  scale,  and  observations  were  made  on  many  of  the  lower  animals ; 
but  the  report,  issued  in  1891,  was  a  corroboration  of  the  conclusions 
reached  by  the  First  Commission. 

Medication  before  Anesthesia. — In  1881,  Alexander  Crombil,  Sur- 
geon at  the  Calcutta  Medical  College  Hospital,  strongly  advocated  a 
combination  of  the  use  of  morphin  and  chloroform.  He  said  that  he 
had  never  seen  a  death  from  chloroform,  and  ascribed  his  success  to  the 
use  of  a  hypodermic  of  morphin  before  the  administration  of  the  chloro- 
form. This  idea  came  from  Claude  Bernard,  who  reported  experiments 
on  dogs  along  similar  lines  in  1869.  Another  attempt  to  show  the 
cause  of  death  under  chloroform  was  made  by  Lauder  Brunton  in  1887. 
He  stated  his  theory  to  show  that  incomplete  anesthesia  with  chloro- 
form was  the  most  frequent  cause  of  fatal  results.  George  Foy,  in  1889, 
supported  these  views. 

The  Use  of  Chloroform  Accompanied  with  Danger.^ — The  Second 
Committee  of  the  British  Medical  Association  appointed  to  investigate 
the  effects  of  anesthetics,  their  safety,  and  methods  of  administration, 
after  studying  reports  of  36,000  cases  in  hospital  and  private  practice, 
concluded  that  no  method  of  using  chloroform  was  free  from  danger. 
They  found  ether  singularly  safe  in  healthy  individuals,  though  minor 
troubles  more  commonly  resulted  from  its  use.  Their  final  conclusion 
was  that  the  most  important  factor  in  the  administration  of  anesthetics 
was  the  experience  already  acquired  by  the  administrator. 

The  Third  Committee  of  the  British  Medical  Association  was  ap- 
pointed in  1901,  to  put  the  determination  of  chloroform  quantitatively 
upon  a  sound  basis.  They  endeavored  to  discover  the  smallest  possible 
dose,  by  volume  in  the  atmosphere  breathed,  necessary  to  produce  an- 
esthesia; and  also  the  smallest  possible  dose  necessary  to  maintain 
anesthesia  after  loss  of  consciousness.  They  recommended  an  inhaler 
devised  by  Vernon  Harcourt,  which  permitted  a  maximum  of  2  per 
cent  of  chloroform  vapor  with  gradations  downward. 

Chloroform  and  Oxygen. — In  an  attempt  to  make  chloroform  safer 
for  anesthetic  purposes,  ISTeudorfer,  of  Vienna,  introduced  the  use  of 
chloroform  and  oxygen  in   1886.^   Bertel   advocated  it  before  the   St. 

'His  method  was  described  in   the  Lon.  Med.  Becord, 


THE    HISTORY    OF    ANESTHESIA  27 

Petersburg  Medical  Society,  as  also  did  von  Idelson.  It  did  not  gain 
favor  because  of  the  lack  of  a  device  for  regulating  proportions.  Kreutz- 
mann,  of  San  Francisco,  in  1887,  wrote  a  description  of  a  simple  ar- 
rangement for  administering  chloroform  and  oxygen.  He  used  the 
Junker  Inhaler  and  spoke  very  highly  of  the  results.  He  commented 
on  its  greater  rapidity,  lack  of  marked  excitement,  quicker  return  to 
consciousness  and  fewer  unpleasant  after-effects.  On  January  25,  1896, 
the  Britisli  Medical  Journal  stated  that  the  number  of  cases  of  the  use 
of  chloroform  and  oxygen  were  then  too  few  for  any  general  conclusions 
to  be  drawn.  Oxygen  was  used  with  chloroform  by  Schall,  of  Brooklyn, 
in  1895,  and  Northrop,  of  Philadelphia,  and  this  combination  has  been 
the  routine  anesthetic  in  a  hospital  of  Pittsburgh  for  nine  years. 

Combinations  and  Sequences  in  Anesthetics. — Among  other  recent 
advances,  it  may  be  noted  that  anesthetics  are  used  more  in  combination 
and  sequence  than  ever  before.  In  pulmonary  anesthetics,  the  placing 
of  rebreathing  upon  a  scientific  basis  by  Gatch,  and  the  combination  of 
general  and  local  anesthetics  by  Crile,  are  noteworthy  advances.  Por 
spinal  and  regional  anesthesia,  electrical,  rectal,  intratracheal  insuiflation, 
morphin,  and  intravenous  anesthesia,  and  hypnotism,  the  reader  is  re- 
ferred to  the  chapters  dealing  especially  with  the  different  forms  of 
anesthesia. 

Ethyl  Chlorid. — Ethyl  chlorid  is  being  used  more  and  more  where 
it  is  impossible  to  use  nitrous  oxid,  on  account  of  the  diflfieulty  of  pro- 
curing the  gas  in  tanks,  etc.,  in  certain  localities. 

Its  general  properties  were  discovered  by  Carlson  in  1896;  in  1902, 
it  was  introduced  in  England  as  a  general  anesthetic,  and  in  the  latter 
country  it  has  recently  almost  displaced  nitrous  oxid. 

Importance  of  Trained  Anesthetists. — The  tendency  of  the  present 
day  is  toward  absolute  accuracy  in  the  choice  of  anesthetics  and  in  the 
amount  administered.  This,  together  with  a  competent  anesthetist  who 
has  been  thoroughly  trained  for  that  particular  work,^  insures  to  the 
patient  of  the  twentieth  century  complete  oblivion  from  pain  during 
surgical  operations,  with  a  minimum  of  discomfort  and  risk. 


BIBLIOGRAPHY 

"Anaesthetics  Ancient  and  Modern ;  an  Historical  Sketch  of  Anaesthesia." 
Burroughs,  Wellcome  &  Co.,  London,  1907. 

Bigelow,  Henry  J.:  "Surgical  Anaesthesia,  Addresses  and  Other  Pa- 
pers."   Boston,  1900. 

Buxton,  Dudley  W. :  "Crawford  Williamson  Long  (1815-1879),  the 
Pioneer  of  Anaesthesia,  and  the  First  to  Suggest  and  Employ  Ether 

1  See  Chap.  IX,  p.  361. 


28  ANESTHESIA 

Inhalation  during  Surgical  Operations."    Eeprinted  from  the  Pro- 
ceedings of  tlie  Royal  Society  of  Medicine,  1912^  5,  19-45. 

Colton,  J.  Q. :  "Anaesthesia :  Who  Made  and  Developed  This  Great  Dis- 
covery ?"  ■  A.  G.  Sherwood  &  Co.,  New  York,  1886. 

"A  True  History  of  the  Discovery  of  Anesthesia,"  A.  G.  Sher- 
wood &  Co.,  New  York,  1896. 

Emerson,  E.  W. :  "A  History  of  the  Gift  of  Painless  Surgery."  Hough- 
ton, Mifflin  &  Co.,  Boston  and  New  York,  1896. 

Foster,  Burnside:  "The  History  of  the  Discovery  of  Anesthesia."  St. 
Paul,  Minn.,  1896. 

Foy,  G. :     "Anaesthetics,  Ancient  and  Modern."     London,  1889. 

Hayden,  William  E. :  "History  of  Anesthesia,  or  Painless  Surgery." 
Inter.  J.  Surg.,  New  York,  1896. 

Hodges,  Eichard  Manning:  "The  Introduction  of  Sulphuric  Ether," 
1891. 

Lyman,  Henry  M. :  "The  Discovery  of  Anesthesia."  Va.  Med.  Mon., 
Sept.,  1886. 

McManus,  James :  "Notes  on  the  History  of  Anesthesia."  Hartford, 
Clark  &  Smith,  1894. 

Maduro:  "The  Status  of  General  Anesthesia,  in  1900."  Med.  News, 
Sept.,  1900. 

Morton,  William  James :  "Memoranda  Eelating  to  the  Discovery  of 
Surgical  Anesthesia,"  and  Wm.  T.  G.  Morton:  "Eelation  to  This 
Event."    New  York,  1905. 

Nevius,  Laird  W. :  "The  Discovery  of  Modern  Anesthesia.  By  Whom 
Was  It  Made?    A  Brief  Statement  of  Facts."    New  York,  1894. 

Old  Penn,  April  6,  1912,  10,  No.  19,  587. 

Patton,  J.  M. :    "Anesthesia  and  Anesthetics." 

"Eeport  to  the  House  of  Eepresentatives  of  the  United  States  of  Amer- 
ica, Vindicating  the  Eights  of  Charles  T.  Jackson  to  the  Discovery 
of  the  Ansesthetic  Effects  of  Ether  Vapor,  and  Disproving  the  Claims 
of  W.  T.  G.  Morton,  to  That  Discovery.  Testimony  in  Eelation  to 
the  Claims  of  Dr.  Horace  Wells,  with  Evidence  Explanatory 
Thereto."    Washington,  1853. 

Eice,  Nathan  P. :    "Trials  of  a  Public  Benefactor."    New  York,  1859. 

Shaw,  S.  Parsons:  "Who  Discovered  Anesthesia?"  Palmer  &  Howe, 
Manchester,  1868. 

Sims,  James  Marion :  "The  Discovery  of  Anesthesia."  J.  W.  Ferguson 
&  Son,  Eichmond,  1877. 

Simpson,  Sir  James  Young:  "Anesthesia,  etc."  D.  Appleton  &  Co., 
New  York,  1872. 

■ "Answer  to  Eeligious  Objections  Advanced  Against  the  Em- 
ployment of  Anaesthetic  Agents  in  Midwifery  and  Surgery."  Lon- 
don, 1847. 


THE    HISTORY    OF    ANESTHESIA  29 

Smith,  Truman :    "An  Inquiry  into  the  Origin  of  Modern  Anesthesia." 

Hartford,  Brown  &  Gross,  1867. 
"Testimony  Establishing  the  Claim  of  William  T.  G.  Morton,  M.D.,  on 

the  Ether  Discovery." 
"The  Semi-Centennial  of  Anesthesia,   October  16,  1896/'  Mass.   Gen. 

Hospital,  Boston,  1897, 
United  States  Congress.     Senate  Eeport  from  Select  Committee,  etc., 

32nd  Congress,  2nd  Session,  Eep.  Com.  No.  421,  Feb.  19,  1853. 
Warren,  Edward:     "Some  Account  of  the  Letheon,  or  Who  Was  the 

Discoverer?"     Dutton  &  Wentworth,  Boston,  1847. 
Warren,  J.  Collins:     "The  Influence  of  Anesthesia  on  the  Surgery  of 

the  Nineteenth  Century,"  1896. 
Warren,  J.  M. :    "The  History  of  Anesthetics  from  an  American  Point 

of  View." 
Welch,  William  H. :     "A  Consideration  of  the  Introduction  of  Surgi- 
cal Anesthesia." 
Young,  Hugh  H. :     "Long,  the  Discoverer  of  Anesthesia."   Johns  Hop- 

Uns  Hist.  Bull.,  Nos.  77-78,  Aug.-Sept.,  1897. 


CHAPTEE    II 
GENEEAL    PHYSIOLOGY    OF    INHALATION    ANESTHESIA 

Inteoductory  Eemarks  :  Definition  of  Terms ;  Chief  Anesthetic 
Agents. 

Theories  of  tpie  Action  of  General  Anesthetics:  Spencer's 
Theory;  Binz's  Theory;  Bernard's  Theory;  Dubois'  Theory;  Schleich's 
Theory;  Miiller's  Theory;  Meyer-Overton  Theory;  Wright's  Theory; 
Traube's  Theory;  Mathews-Brown  Theory;  Moore-Eoaf  Theory;  Gill's 
Theory;  Hober's  Theory;  Baglioni's  Theory;  Eeicher's  Theory;  Gros's 
Conclusions ;  Burker's  Theory ;  Verworn's  Theory ;  Conclusions  of  Lillie ; 
Conclusions. 

Effects  of  Inhalation  Anesthetics  upon  Various  Parts  of  the 
Organism  :  The  Bespiratory  System ;  The  Circulatory  System ;  The 
Muscular  System;  The  Glandular  System;  The  Nervous  System. 

Factors  Which  May  Be  Said  to  Modify  the  Physiology  of 
Anesthesia  as  Ordinarily  Induced:  Warming  the  Agent;  Experi- 
ments on  Warming  Ether ;  Effects  of  Moisture ;  Combining  Oxygen  with 
the  Agent ;  The  Influence  upon  Anesthesia  of  Oxygen  Intra-abdominally 
Administered ;  Preceding  the  Administration  with  Oil  of  Bitter  Orange 
Peel ;  Utilizing  Carbon  Dioxid. 

INTRODUCTORY    REMARKS 

All  attempts  to  give  a  detailed  account  of  the  action  of  anesthetic 
agents  in  general  upon  the  organism  reveal  the  practical  impossibility 
of  proceeding  very  far  without  employing  a  modifying  phrase,  "this 
varies  with  the  agent  employed,"  "according  to  conditions,"  "with  chlo- 
roform," "with  ether,"  etc.  Therefore  relatively  little  space  is  given 
here  to  the  general  physiology,  special  attention  being  directed  to  the 
particular  physiology  of  each  agent  in  the  individual  chapters  where 
the  several  drugs  are  discussed  in  detail.  In  fact,  the  special  physiology 
of  ether,  chloroform,  or  other  inhalation  anesthetic  agent,  is  of  far  more 
value  to  the  practical  anesthetist  than  is  the  physiology  which  is  applica- 
ble alike  to  all,  the  former  having  been  evolved  largely  from  clinical  ob- 
servation, whereas  the  latter  is  the  outcome  chiefly  of  laboratory  ex- 
perimentation, many  points  concerning  which  have  not  been  definitely 
determined. 

30 


GENERAL  PHYSIOLOGY  OF  INHALATION  ANESTHESIA     31 

Definition  of  Terms. — The  term  "general  anesthetic"  is  employed  in 
contradistinction  to  local  or  spinal  analgesic.  The  state  of  general  an- 
esthesia, or  unconsciousness  concurrent  with  insensibility  to  pain,  is 
usually  brought  about  by  inhalation,  but  may  be  induced  by  various 
agencies  introduced  into  the  organism  by  other  channels  than  the 
respiratory  system.  It  may  perhaps  also  be  induced  by  hypnotism  and 
electrical  influences. 

The  various  narcotic  and  analgesic  drugs  which  are  administered  by 
mouth  or  otherwise  are  excluded  from  discussion  in  this  chapter. 

The  state  induced  by  the  administration  of  inhalation  anesthetics 
is  designated,  by  the  usually  accepted  phraseology,  general  anesthesia, 
anesthesia,  and  narcosis,  all  signifying  unconsciousness  with  general 
loss  of  sensation,  including,  of  course,  loss  of  pain  sense. 

Analgesia,  loss  of  sensibility  to  pain,  is  not  to  be  confounded  with  the 
above  terms.  The  terms  "light  anesthesia"  and  "heavy  anesthesia," 
whose  use  has  been  challenged  by  some  writers  ^  are  not  in- 
correct, if  considered  to  apply  merely  to  degrees  or  stages  of  anes- 
thesia. 

Certain  factors  are  generally  accepted  as  entering  into  the  physico- 
chemical  relations  of  the  anesthetic  agent  to  the  organism,  giving  rise 
to  results  which  may  be  noted  and  controlled  clinically.  These  factors 
are  as  follows: 

(1)  It  should  be  of  such  nature  or  combination,  or  must  be  capable 
of  such  methods  of  administration,  as  will  reduce  the  danger  to  life  to 
a  minimum. 

(2)  The  anesthetic  agent  should  possess  such  physical  properties 
that  it  is  easily  taken  into  the  system. 

(3)  It  should  produce  the  general,  complete,  or  temporary  inhibi- 
tion of  action  of  the  nervous  mechanism  presiding  over  cerebration, 
sensation,  and  motion, 

(4)  It  should  be  capable  of  administration  with  the  least  inter- 
ference with  respiration,  circulation,  or  other  vital  processes. 

(5)  It  should  act  in  such  manner  that  its  immediate  effects  are 
at  all  times  under  the  control  of  the  administrator. 

(6)  It  should  reduce  general  shock  to  a  minimum. 

(7)  It  should  not  cause  serious  or  lasting  after-effects,  the  organism 
promptly  resuming  the  physiological  functions  existent  immediately 
before  the  administration  of  the  anesthetic. 

In  the  light  of  recent  laboratory  and  clinical  experiments,  a  further 
requirement  may  be  added  to  those  heretofore  generally  accepted  as 
applying  to  the  satisfactory  inhalation  anesthetic ;  this  is : 

(8)  The  agent  should  be  of  such  a  nature  or  combination  as  to  render 
possible  the  practically  complete  elimination  of  the  second  stage  of  an- 

'"Eeview  of  Blumfeld's  Treatise,"  Lancet,  Sept.  21,  1912. 


32  ANESTHESIA 

esthesia — the  stage  of  excitement — during  which  the   dangerous   phe- 
nomena of  anesthesia  are  often  noted. 

Chief  Anesthetic  Agents. — The  chief  agents  and  combinations  of 
agents  which  fulfil  the  above  requirements  are:  (1)  nitrous  oxid;  (2) 
ether;  (3)  ethyl  chlorid;  (4)  chloroform;  (5)  combinations  and  se- 
quences of  the  above  with  each  other  and  with  oxygen. 

THEORIES   OF   THE   ACTION   OF   GENERAL   ANESTHETICS 

Inasmuch  as  there  are  still  "mysteries  of  anesthesia/'  many  points  of 
physiology  upon  which  expert  opinions  differ,  we  present  a  brief  review 
of  the  theories  concerning  the  mode  of  action  of  anesthetics,  as  ad- 
vanced by  the  earlier  investigators  as  well  as  by  more  recent  writers. 
No  attempt  has  been  made  to  catalogue  all  the  theories  proposed,  or  to 
follow  strict  chronological  sequence. 

Spencer's  Theory.^ — Narcotic  and  anesthetic  agents  are  commonly 
supposed  to  have  special  relations  to  the  nervous  tissue,  rather  than  to 
other  tissues.  Because  of  the  different  effects  produced,  it  is  even  sup- 
posed that  some  of  them  have  elective  affinities  for  the  matter  composing 
certain  nervous  centers  rather  than  for  that  composing  others.  As  the 
same  anesthetic  does  not  act  in  the  same  way  on  all  persons,  but  here 
affects  one  center  more,  and  there  another,  it  must  be  assumed  that 
the  chemical  compositions  of  these  centers  are  in  such  cases  interchanged. 
Since,  in  the  same  individual,  the  same  quantity  of  the  same  anesthetic 
will  produce  quite  different  effects  in  different  states  of  the  circulation, 
the  hypothesis  requires  the  supposition  that  these  contrasts  of  chemical 
composition  among  the  nervous  centers  interchange  from  hour  to  hour. 

The  various  substances  that  affect  the  nervous  system — the  narcotic 
and  anesthetic  agents — are  substances  that  produce  changes  in  albumi- 
nous matters,  their  respective  effects  being  modified  by  the  various  con- 
ditions under  which  they  act.  "Agents  having  powerful-  affinities  for 
components  of  the  tissues  and  fluids,''  according  to  Spencer,  "given  in 
small  quantities  to  avoid  destruction  of  the  membranes,  can  scarcely 
reach  the  nervous  system  in  uncombined  states;  and  may  be  expected  to 
work  their  respective  effects  through  the  instrumentalities  of  the  com- 
pounds they  have  formed.  The  most  conspicuous  effects  will  be  wrought 
by  those  agents  which,  while  they  can  produce  molecular  changes  in 
albuminous  substances,  have  not  such  powerful  affinities  for  them,  or 
for  their  elements,  as  to  be  arrested  on  their  way  to  the  nervous  system. 
The  anesthetics  and  narcotics  may  fairly  be  regarded  as  fulfilling  this 
requirement."  It  need  not  be  supposed  that  the  anesthetic  or  narcotic 
has  more  affinity  for  protein-substance  of  nerve  corpuscle  or  nerve  fiber 

^  Spencer,  Herbert :  * '  Synthetic  Philosophy, ' '  Vol.  I ;  "  Principles  of  Psychol- 
ogy,"  Appendix;  "On  the  Actions  of  Anaesthetics  and  Narcotics,"  631. 


GENERAL  PHYSIOLOGY  OF  INHALATION  ANESTHESIA      33 

than  for  the  other  forms  of  protein-substance  with  wliich  it  coinos  in 
contact.  Its  effect  is  comprehensible,  however,  as  resulting  from  the 
structural  relations  of  nerve  corpuscle  and  nerve  fiber. 

In  order  to  understand  why  excitement  precedes  narcosis,  one  must 
observe  the  different  relations  of  nerve  corpuscle  and  nerve  fiber  to  the 
blood.  The  vesicular  tissue  of  the  nervous  system  is  far  more  vascular 
than  its  fibrous  tissue.  While  the  matter  of  the  nerve  vesicles  is  so 
arranged  as  to  offer  the  least  possible  obstacle  to  the  reception  of  the 
fluid  from  the  adjacent  capillaries,  the  matter  of  nerve  fibers  is  shielded 
by  a  medullary  sheath.  When  any  agent,  therefore,  which  is  capal^le  of 
so  changing  the  molecular  state  of  nerve  matter  as  to  arrest  its  function 
is  carried  into  the  blood,  the  first  action  is  upon  the  nerve  corpuscles. 
"Each  change  produced  in  one  of  these,"  according  to  Spencer,  "implies 
a  disengagement  of  molecular  motion  that  is  immediately  propagated 
along  the  connected  nerve  fibers,  and  excites  the  parts  to  which  they 
run.  Every  nerve  corpuscle  being  thus  quickly, acted  upon,  and  emitting 
successive  discharges  as  the  successive  molecular  transformations  are 
wrought  in  it,  there  results  a  general  exaltation  of  state,  physically  in 
the  invigorated  pulse  and  contractions  of  the  muscles,  and  as  shown 
psychically  in  the  rush  of  vivid  ideas  and  intensified  feelings."  While 
this  is  going  on,  while  some  molecules  of  the  anesthetic  agent  have  thus 
quickly  passed  from  the  closely  adjacent  capillaries  into  the  almost 
naked  matter  of  the  nerve  corpuscles,  other  such  molecules  are  elsewhere 
on  their  way  through  the  outer  coats  of  the  nerve  tubes  and  the  medul- 
lary sheaths  within  these,  reaching,  in  time,  the  bundles  of  fibrillse 
forming  the  axis-cylinders.  The  isomeric  changes  which  they  immedi- 
ately begin  to  produce  in  these  at  first  add  to  the  general  excitement. 
As  the  anesthetic  invades  a  nerve  fiber  more  and  more,  a  greater  and 
greater  number  of  its  molecules  are  rendered  unable  to  transfer  a  wave 
of  the  peculiar  isomeric  change  which  constitutes  a  nervous  discharge, 
and  finally  the  fiber  becomes  impermeable. 

The  impermeability,  other  things  being  equal,  takes  place  sooner 
in  the  longer  nerve  fibers  than  in  the  shorter,  the  probability  being 
that,  after  a  given  interval,  a  long  fiber  is  more  likely  than  a  short 
fiber  to  be  invaded  at  some  parts  of  its  course.  This  presumably  ex- 
plains why,  in  an  animal,  anesthesia  occurs  first  in  the  hinder  extremi- 
ties, the  parts  of  the  surface  nearer  to  the  nervous  centers  losing  their 
sensibility  later. 

ISTumerous  factors  (point  of  absorption;  rapidity  of  absorption; 
quantity  absorbed ;  relative  molecular  mobility  of  the  agent ;  its  chemical 
relation  to  the  blood  and  other  substances;  general  state  of  circulation 
and  of  circulation  in  each  nervous  center;  and  character  of  nerve  fibers 
acted  upon)  cooperate  to  cause  variation  in  the  effects  produced  by  the 
various  agents,  by  different  doses  and  by  the  same  dose  under  different 


34  ANESTHESIA 

conditions.  It  is  not  necessary,  therefore,  to  assign  elective  affinities  for 
special  centers  as  the  only  possible  causes  of  the  special  effects. 

Binz's  Theory/ — The  ganglion  cell,  according  to  Binz,  is  the  point 
of  attack  of  the  anesthetic  agent.  In  his  experiments,  fresh  sections  of 
the  brain  cortex  of  rabbits  were  placed  in  a  one  per  cent  solution  of 
morphin  hydrochlorid,  or  exposed  to  chlorin  vapors.  The  effect  of 
coagulation-necrosis  was  produced,  as  is  seen  when  protoplasmic  poisons 
of  neutral  reaction  are  allowed  to  act  upon  large  transparent  infusoria. 
The  protoplasm  is  at  first  darkened,  and  the  movements  become  slug- 
gish; later  on  the  protoplasm  becomes  granulated,  and  the  movements 
cease.  Eecuperation  may  take  place  from  the  first  stage,  by  washing 
away  the  poisons,  but  not  from  the  last  stage.  The  first  stage  is  likened 
by  Binz  to  the  sleep  of  the  cell;  the  last  to  death.  The  first  trace  of 
coagulation  may  redissolve  but  coagulation  itself  does  not. 

Bernard's  Theory.^ — Bernard  regarded  the  ganglion  cell  as  the  point 
of  attack  of  the  narcotic  agent.  In  his  opinion,  the  mechanism  of  an- 
esthesia is  always  the  same,  in  spite  of  the  difference  of  the  narcotic 
agent;  for  they  all  produce  one  identical  modification  in  the  ganglion 
cell.  This  modification  of  the  ganglion  cell  consists  in  a  semi-coagula- 
tion of^  the  protoplasm  of  the  nerve-cell,  this  semi-coagulation  being 
merely  transitory,  the  protoplasm  resuming  its  previous  state  after  the 
removal  of  the  narcotic  agent  from  the  cell.  This  view  was  derived 
from  the  rigidity  of  muscle  fibers  after  their  exposure  to  chlorin  vapors. 

Miiller  ^  points  out  that  the  same  mechanism  cannot  be  assumed  to 
underlie  all  narcoses,  the  mechanism  of  indifferent  narcotics  differing 
from  the  mechanism  of  narcosis  caused  by  many  basic  narcotics.  He 
believes,  however,  that  a  semi-coagulation  of  the  protoplasm  is  pro- 
duced hy  the  majority  of  the  basic  narcotics. 

Dubois'  Theory.* — Dubois  proposed  a  modification  of  Bernard's 
theory,  holding  that  narcotics  act  hy  producing  a  dehydration  of  the 
protoplasm,  or  by  decreasing  the  dissociation  of  the  inMhition-water 
of  the  tissues.  Organisms  which  are  exposed  to  the  action  of  these 
dehydrating  substances  are  transformed  into  a  state  of  latent  vitality. 

Miiller  ^  points  out  that  this  theory  is  entirely  erroneous,  the  water 
that  is  withdrawn  being  derived  from  the  "cell  juice,"  but  not  from  the 
protoplasm.     Eichet  states  that  a  compound  becomes  a  more  efficient 

^Binz,  C:  "  Ueber  Anaesthetika, "  Deutsche  Klinik,  1860,  No.  29,  277; 
"Ozonisierte  Luft,  ein  schlafmachendes  Gas,"  Berl.  Min.  Wochnschr.,  1882, 
No.  1,  6;  "Die  Wirkung  ozonisierter  Luft  auf  das  Gehirn, "  Berl.  Iclin. 
Wochnschr.,  1884,  No.  40,  633. 

^Bernard,  C:     "  L 'anesthesie,  "  Union  med.,  Paris,  1869,  8,  109. 

'Miiller,  B.:   " Narkologie, "   7. 

"Dubois,  E. :  "Contribution  a  I'etude  de  la  physiologie  generale  des  anes- 
thesiques,"  Seances  et  Mem.  Soc.  de  Biol.,  Oct.  24,  1885,  625. 

°  Miiller :     Loc.  cit. 


GENERAL  PHYSIOLOGY  OF  INHALATION  ANESTHESIA      35 

narcotic,  or  a  stronger  poison,  the  slighter  its  solubility  in  water.  This 
assertion  applies  to  a  definite  number  of  narcotics,  up  to  a  certain  de- 
gree. All  indifferent  narcotics,  of  difficult  solubility  in  water,  have  the 
property  of  penetrating  quickly  to  the  entire  protoplasm  and  require 
only  a  few  seconds  to  get  into  the  cell  juice.  Overton's  statement  holds 
good,  that  the  strongest  narcotics  are  those  compounds  which  at  the 
same  time  combine  a  very  slight  solubility  in  water  with  a  very  great 
solubility  in  ether,  olive  oil,  or  the  lecithin  mixtures. 

Schleich's  Theory.^ — According  to  Schleich,  the  first  influence  of  the 
anesthetic  agent  is  manifested  hy  the  stimulation  of  peripheral  organs, 
followed  hy  local  stimulation  at  the  end  apparatus  of  the  sense-organs. 
The  effects  upon  the  central  apparatus  are  as  follows : 

The  blood  circulates  in  the  neuroglia  in  very  fine  vessels,  and  the 
first  effect  of  the  narcotic  is  felt  as  a  heavy,  dull  sensation  over  the 
entire  head;  the  result  of  the  neuroglia  irritation  would  be  sleep,  if 
the  ganglion  cells  were  not  themselves  stimulated  at  about  the  same 
time.  As  a  matter  of  fact,  this  sleep  can  be  produced  in  the  early  stage 
in  certain  individuals,  for  example  in  children,  by  very  gradual  an- 
esthetization. The  small  quantities  of  the  anesthetic  which  at  first  cir- 
culate in  the  blood  may  cause  a  stimulation  of  the  vasomotors,  and 
thereby  a  narrowing  of  the  vessels,  on  account  of  the  close  connection 
of  the  neuroglia  protoplasm  cells  with  the  vessels.  The  function  of  the 
protoplasm  cells  is  thereby  diminished,  due  to  limited  fluid;  the  inhi- 
bition is  lessened;  ideas  and  thoughts  travel  about  unchecked.  It  is 
not  until  the  onset  of  vasomotor  paralysis  that  the  vessels  become  larger, 
so  that  the  narcotic  agent  can  stimulate  the  protoplasm  cells  directly. 
The  roaming  ideas  are  now  restricted.  The  inhibitory  function  of  the 
neuroglia  advances  and  penetrates  between  the  individual  sensory  asso- 
ciations. The  situation  becomes  blurred;  momentary  consciousness  is 
lost;  only  individual  ideas  reach  consciousness;  the  condition  takes  on 
more  and  more  similarity  to  sleep,  at  first  restless  and  full  of  dreams, 
later  on  deep  and  quiet.  The  pupils  are  still  sensitive  to  light  stimuli, 
but  no  longer  reach  their  full  width  on  closure  of  the  lids ;  the  contrac- 
tion increases  as  the  narcosis  advances.  The  pupils  are  contracted  also 
in  sleep.  There  probably  exists  a  reflex  arc  between  neuroglia  irrita- 
tion and  oculomotor  function,  or  sympathetic  paralysis,  respectively. 

Poisons  such  as  chloroform  are  relatively  mild,  because  they  are 
first  accompanied  by  neuroglia  irritation,  whereas  the  true  cell  poisons 
penetrate  at  once  into  the  ganglion  cells,  exerting  their  relative  influence 
beyond  the  protective  action  of  the  neuroglia,  and  acting  upon  the  gan- 
glion cells  by  way  of  the  lymph  spaces  and  blood  vessels.  Narcoses  with 
chloroform,  ether,  alcohol,  etc.,  are  increased  physiological  mechanisms, 
namely,  changes  in  repletion  with  blood  and  irritations  of  the  neuroglia. 

'Schleich:      "Zur   Infiltrations   Anaesthesie, "    Therap.   Monatsh.,   1894,    429. 


36  ANESTHESIA 

When  these  substances  are  administered  in  definite  quantities  which 
create  a  state  of  equilibrium  between  the  action  of  the  narcotic  and  the 
power  of  resistance  of  the  neuroglia,  their  effect  becomes  narcotic,  and 
this  effect  increases  the  more  the  scale  of  equilibrium  tips  toward  the 
narcotic,  until  finally  the  neuroglia  is  overcome,  and  the  effect  is  then 
the  same  as  that  of  the  cell  poisons  which  directly  attack  the  ganglion 
cell,  omitting  the  neuroglia. 

Schleich  considers  the  narcotic  agents  as  primary  neuroglia  poisons, 
and  their  antagonists  (the  cell  poisons)  as  primary  cell  poisons.  He 
also  assumes  a  variable  sensitiveness  of  the  neuroglia  in  the  different 
developmental  stages.  The  effect  of  chloroform,  and  the  majority  of 
narcotics,  upon  the  individual  centers  of  the  human  brain,  pursues  a 
course  in  inverse  ratio  to  the  phylogenetic  development  of  the  centers. 
The  extraordinarily  poisonous  effect  of  chloroform  and  of  morphin 
upon  certain  individuals  is  explained  by  him  as  due  to  the  fact  that,  in 
these  cases,  the  neuroglia  does  not  react  to  the  ordinary  toxic  dose  by  a 
stimulation,  but  directly  by  paralysis. 

Miiller's  Theory.^ — After  considering  various  theories  of  narcosis, 
Miiller  formulated  his  own  view  concerning  the  mechanism  of 
anesthesia. 

After  the  narcotic  agent  has  reached  the  ganglion  cells  of  the  cere- 
bral cortex,  it  exerts  its  actiofi  upon  tlie  lecithin-cliolesterin  mixture  of 
the  ganglion  cell,  causing  it  to  undergo  a  physical  transformation.  Ac- 
cording to  Schleich's  theory,  the  plasma  cells  of  the  neuroglia  are  also 
important  and  possess  inhibitory  properties;  they  surround  each  func- 
tionating ganglion  cell  and  communicate  directly  with  a  vessel.  As 
the  plasma  cells  are  directly  connected  with  the  perivascular  lymph 
spaces  of  the  vessels,  and  are  themselves  surrounded  by  lymph  spaces, 
the  narcotic  agent  which  is  contained  in  a  definite  concentration  in 
the  blood  plasm  must  be  taken  up  by  the  lymph  of  the  lymph  spaces, 
and  an  equilibrium  in  the  concentration  of  the  two  fluids  in  the  narcotic 
must  become  established.  It  depends  upon  the  composition  of  the  proto- 
plasm of  the  plasma  cells,  how  much  narcotic  they  will  take  up  before 
this  reaches  the  ganglion  cell.  The  paralysis  of  the  plasma  cell  rep- 
resents that  instant  at  which  the  quantity  of  the  narcotic  in  the  plasma 
cell  is  such  that  no  additional  amount  can  be  taken  up.  The  narcotic, 
at  this  moment,  gets  also  into  the  ganglion  cell.  The  plasma  cell  is  now 
passed  without  its  protoplasm  taking  up  anything  of  the  narcotic,  and 
the  ganglion  cell  takes  up  the  narcotic  from  the  intercellular  lymph. 
The  function  of  the  neuroglia  explains  the  different  effects  of  the  nar- 
cotic upon  the  individual  centers.  By  assuming  the  presence  of  lecithin- 
cholesterin  mixtures  also  in  the  plasma  cells,  it  becomes  intelligible  that 
they  possess  the  capacity  of  dissolving  the  narcotic  agents.     Possibly, 

^  Miiller,  B. :     Loc.  cit. 


GENERAL  PHYSIOLOGY  OF  INHALATION  ANESTHESIA      37 

these  plasma  cells  contain  still  anotlicr  similar  substance,  which  floes 
not  exist  in  the  ganglion  cells,  and  tlioi-cby  invests  the  plasma  cells 
with  the  capacity  of  fixing  still  larger  qiiaiitiiies  of  the  narcotic.  This 
other  body  may  be  contained  in  larger  amounts  in  the  phylogencti(;ally 
older  plasma  cells  than  in  the  younger  cells,  thus  accounting  for  tlie 
prolonged  resistance  in  still  another  way.  The  significance  of  the 
solubility  of  the  narcotic  in  the  cells  of  the  neuroglia  is  at  once  evident, 
when  the  function  of  the  neuroglia  is  interpreted  as  something  more 
than  connective  tissue  function.  The  different  efi^ect  upon  the  ganglion 
cells  is  explained  by  the  different  niimber  of  existing  plasma  cells.  The 
action  of  the  neuroglia  consists  in  modifying  the  solubility  of  the  nar- 
cotic agent  and  thereby  controlling  the  rate  of  its  penetration  into  the 
ganglion  cells. 

Meyer-Overton  Theory. — In  189 C  Hans  Meyer  announced  his  theory 
of  narcosis ;  ^  the  following  year  E.  Overton  described  his  theory  of  anes- 
thesia;^ and  in  1905  Meyer  restated  his  theory. -"^  Since  these  two 
theories  were  formulated  independently  and  without  conference,*  and 
in  general  agree,  this  explanation  of  anesthesia  is  usually  referred  to  as 
the  Meyer-Overton  theory. 

According  to  Meyer,  the  narcotizing  substance  enters  into  a  loose 
physico-cliemical  combination  ivith  the  vitally  im.portant  lipoids  of  tlie 
cell,  perhaps  with  lecithin,  and  in  so  doing  changes  their  normal  rela- 
tionship to  the  other  cell  constituents,  through  ivhich  an  inhibition  of 
the  entire  cell  chemism  results.  The  narcosis  disappears  as  soon  as  the 
loose,  reversible  combination,  dependent  upon  the  solution  tension, 
breaks  up. 

In  accordance  with  these  views  Meyer  formulated  the  following 
statements : 

"(1)  All  primarily  indifferent  chemical  substances  which  are  solvents 
for  fat  and  substances  resembling  fat  must  exert  a  narcotic  action  upon 
living  protoplasm,  in  so  far  as  they  can  diffuse  therein. 

"(2)  The  effect  must  manifest  itself  first,  and  most  strongly,  in  those 
cells  in  whose  chemical  structure  these  fatty  or  lipoid  substances  pre- 
dominate and  presumably  are  the  essential  carriers  of  the  cell  function, 
— namely,  in  the  first  place,  in  the  nerve  cells. 

"(3)  The  relative  efficiency  of  such  narcotic  agents  must  be  de- 
pendent upon  their  mechanical  affinity  for  lipoid  substances,  on  the 
one  hand,  and  for  the  remaining  body  constituents,  i.  e.,  princijjally 

^ArcMv  f.  exper.  PatJiol.  u.  Pharmakol.,  May  16,  1899,  110,  119. 

" ' '  Studien  iiber  die  Narkose,  zugleich  ein  Beitriig  zur  allgemeiuen  Phar- 
makologie, "  Jena,  1901. 

^ ' '  The  Theory  of  Narcosis, ' '  Harvey  Lectures,  1905,  1 ;  J.  Am.  Med.  Assn., 
Jan.  20,  1906,  167. 

*J.  Am.  Med.  Assn.,  Jan.   29,  1906,  169. 


38  ANESTHESIA 

water,  on  the  other  hand.  It  is  dependent,  therefore,  upon  the  division 
coefficient  which  determines  their  distribution  in  a  mixture  of  water 
and  lipoid  substances." 

Overton  carried  out  extensive  observations  and  investigations  con- 
cerning the  osmotic  properties  of  living  plant  cells  and  animal  cells, 
followed  by  experimentation  with  general  anesthesia.  He  was  firmly 
convinced  of  the  fact  that  the  mode  of  action  of  anesthetic  agents  can 
in  no  way  be  explained  on  the  basis  of  chemical  reaction ;  for  the  reason 
that  many  of  the  strongest  indifferent  narcotics  belong  chemically  to 
the  most  stable  and  sluggish  compounds.  The  effect  of  narcotic  agents 
is  essentially  a  function  of  their  lipoid  solubility. 

Overton  showed  that  substances  may  be  divided  into  different  groups 

according  to  the  rapidity  with  which  they  diffuse  into  protoplasm,  the 

rate  of  diffusion,  as  a  general  rule,  depending  upon  the  solubility  of 

the  substances  in  fat,  lecithin,  and  lipoid  substances  of  that  type.     If 

Sr  represents  the  solubility  of  the  substance  in  fat,  and  S^   that  of 

o 
the  same  substance  in  water,  then  the  ratio    — ^     is  termed  the  distri- 

bution  coefficient  of  the  substance.  According  to  Overton,  the  value  of 
this  coefficient  determines  the  velocity  of  diffusion  into  cell  protoplasm. 

It  has  been  indicated  by  Meyer  and  Overton^  that  anesthetics  and 
narcotics  are  usually  substances  which  diffuse  rapidly,  and  that,  there- 
fore, these  substances  should  have  a  high  distribution  coefficient.  Meyer 
accordingly  compared  the  aliphatic  narcotics,  and  found  that  the  nar- 
cotic power  of  these  was  roughly  proportional  to  the  magnitude  of  the 
distribution  coefficient.  This  finding  has  been  expressed  as  follows: 
The  strength  of  the  narcotic  action  of  a  compound  is  dependent  upon 
its  solubility  in  lipoid  substance.^  But,  as  has  been  pointed  out  by  May,^ 
this  is  not  exactly  correct,  since  it  depends  not  so  much  on  its  actual 
solubility  in  lipoid  substances  as  upon  the  ratio  of  its  solubility  in  lipoids 
to  that  of  its  solubility  in  water." 

Meyer  compared  the  narcotic  power  of  the  aliphatic  narcotics  by 
ascertaining  the  smallest  concentration  which  would  produce  a  definite 
physiological  effect,  and  he  expressed  the  values  as  fractions  of  a  normal 
solution,  calling  these  the  "liminal  values."  He  and  Baum*  discussed 
the  work  of  Dubois  ^  in  reference  to  which  they  advanced  the  theory  that 
the  relative  strengths  of  anesthetics  are  dependent  upon  their  mechan- 
ical affinity  for  fatty  substances,  like  lecithin  in  the  protoplasm,  on  the 
one  hand,  and  to  the  other  constituents  in  the  protoplasm,  especially 

^  Arch.  f.  exp.  Path.  u.  Pharm.,  1901,  42,  109  and  119. 

^  See  Hober's  Theory,  p.  46. 

^  Loc.  cit. 

*  Arch.  f.  exp.  Path.  u.  Pharm.  42,  109. 

*See  Dubois'  Theory,  p.  34. 


GENERAL  PHYSIOLOGY  OF  INHALATION  ANESTHESIA     39 

water,  on  the  other  hand.  In  support  of  these  views,  they  showed  that 
the  proportion  between  solubility  in  fat  and  solubility  in  water  of  a 
number   of   narcotics   runs   parallel   with   their   anesthetizing   activity. 

The  theory  of  Overton  and  Meyer  is  well  supported  by  the  paral- 
lelism of  narcotic  effect  and  distribution  coefficient.  Then,  too,  a  num- 
ber of  subsidiary  facts  appear  to  lend  it  additional  support ;  for  example, 
the  observation  of  Mansfield,^  that  some  narcotics  have  a  more  powerful 
action  when  administered  to  starved  animals,  the  explanation  suggested 
being  that  in  these  there  is  less  tissue  fat  to  absorb  some  of  the  narcotic 
and  that  a  greater  portion  of  the  latter  is  in  consequence  absorbed  by 
the  central  nervous  system;  and  the  observation  of  Tunnicliffe  and 
Eosenheim  -  that  the  addition  of  lecithin  protracts  the  effect  of  chloro- 
form on  the  heart. ^ 

However,  other  facts  seem  to  show  that  the  theory  is,  to  say  the 
least,  incomplete.  For  instance,  the  peripheral  nerves  contain  a  large 
amount  of  lipoid  substance,  yet  they  are  much  less  affected  by  the  ali- 
phatic narcotics.  It  has  also  been  pointed  out  by  Cushny  *  that  inany 
aromatic  compounds  have  a  high  distribution  coefficient,  but  are  never- 
theless devoid  of  narcotic  action.  There  is,  however,  a  possible  expla- 
nation of  these  facts  in  Traube's  theory  (see  p.  48)  of  surface  tension. 

It  appears  reasonable  to  conclude  from  these  facts : 

(1)  That  the  rapid  penetration  of  the  cells  should  be  the  most 
essentia!  condition  of  enabling  a  substance  to  exert  its  effect  on  the 
interior  of  the  cells. 

(2)  That,  after  the  substance  has  gained  entrance,  its  solubility  in 
the  cell  lipoids  may  be  the  important  factor  in  determining  narcotic 
action. 

The  Meyer-Overton  theory  is  more  than  merely  interesting.  It 
ostensibly  gives  a  simple  explanation  of  narcosis  and  seems  to  afford  a 
means  of  elucidating  other  processes,  as  phagocytosis.^  In  support  of 
the  combination  of,  say,  chloroform  with  lecithin,  we  have  the  analogous 
conduct  of  this  compound  with  salicylid,"  leprarin,^  and  even  water ;  ^ 
and  further  support  is  given  to  the  Meyer-Overton  theory  l)y  the  finding 

^Cetitr.  Physiol.,  20,  664. 

^  Froc.  Physiol.  Soc,  1903,  15. 

^  Tunnicliffe  and  Eosenheim  studied  the  action  of  chloroform  and  ether  on 
the  heart  by  adding  them  to  saline  fluid  perfused  through  the  heart  by  Locke's 
method.  The  depressing  action  on  the  heart  produced  by  chloroform  was  found 
to  be  very  marked,  but  if  lecithin  was  also  added  the  effect  was  found  to  be 
delayed. 

*  Cushny:     "Text-book  of  Pharmacology,"   1904,   128. 

=  See  Graham:     J.  Am.  Med.  Assn.,  March  26,,  1910,  1044. 

''Anschiitz:     Ann.,  273,  94. 

'Kassner:     Arch.  Pharm.,  237,  44. 

*See  Z.  anal.  Chem.,  25,  118. 


40  ANESTHESIA 

of  Nerking/  that,  in  the  case  of  animals  to  which  a  solution  of  lecithin 
has  heen  administered,  the  anesthesia  lasted  for  "a  much  shorter  time" 
than  in  the  case  of  the  control  animals,  and  the  work  of  Graham,^ 
who  found  that  lecithin  and  olive  oil  added  to  etherized  blood  restored 
phagocytosis.  Although  the  theory  is  well  supported  by  certain  evidence, 
it  is  too  specific  to  be  altogether  satisfactory. 

There  is  much  uncertainty  as  to  the  mode  of  action  of  anesthetics 
and  particularly  as  to  their  effect  upon  permeability.  While  some  writers 
hold  that  anesthetics  increase  permeability,  others  take  the  opposite 
view.^  As  pointed  out  by  Osterhout,*  to  clear  up  this  confusion  appears 
to  be  a  necessary  step  toward  a  theory  of  anesthesia.  He  seems  to  have 
attained  a  definite  solution  of  the  problem  in  the  cases  he  describes — a 
result  due  to  the  employment  of  quantitative  methods. 

The  experiments  of  Osterhout  were  made  by  measuring  the  con- 
ductance of  living  tissues  of  a  marine  plant,  laminaria.  Under  the  con- 
ditions of  the  experiment,  an  increase  or  decrease  of  conductance 
signified  a  corresponding  increase  or  decrease  of  permeability.^  The 
anesthetics  (ethyl  ether,  chloroform,  chloral  hydrate,  and  alcohol)  were 
mixed  with  sea  water  and  sufficient  concentrated  sea  water  was  then 
added  to  make  the  conductivity  equal  to  that  of  sea  water.  The  material 
was  then  placed  in  the  mixture  and  its  conductance  was  measured  at 
frequent  intervals. 

Two  distinct  effects  were  observable  in  the  experiments  conducted 
by  Osterhout.  One  was  a  toxic  effect  evidenced  by  an  increase  in 
permeability,  while  the  other  involved  a  decrease  in  permeability.  He 
was  forced  to  the  conclusion,  from  the  results  obtained,  that  it  was 
the  reversible  change,  involving  a  decrease  of  permeability,  which  was 
associated  with  the  anesthetic  action.  This  is  indeed  reasonable.''  Os- 
terhout pointed  out  that  the  fact  that  typical  anesthetics  decrease  the 
permeability  of  the  tissue  to  ions  is  significant  in  view  of  the  fact  that 
the  transmission  of  nervous  and  other  stimuli  is  believed  to  depend  on 
the  movement  of  ions  within  the  tissues. 

Wright's  Theory.'' — Wright  undertook  an  investigation  to  determine 

^Miinch.  med.  Wocli.,  1908,   1733. 

-J.  Am.  Med.  Assn.,  March  20,  1910,  1043. 

=*Cf.  Hober:  "  Physikalische  Chemie  der  Zelle  und  der  Gewebe,"  1911,  219, 
223,  489;  Lillie:  Am.  J.  Physiol,  1912,  ^9,  372;  30,  1;  and  Lepeschkin:  Ber.  d. 
hot.  Ges.,  1911,  S9,  349. 

*  Science,  n.  s.,  37,  No.  942,  111. 

■"The  method  is  described  in  Science,  n.  s.,  S5,  112    (1912). 

"  The  distinctive  mark  of  an  anesthetic  is  the  reversibility  of  its  action ; 
hence  it  can  hardly  be  concluded  that  this  action  is  associated  with  an  irre- 
versible change  in  permeability.  Such  a  change  is  not  peculiar  to  anesthetics, 
although  common  to  all  toxic  substances. 

'  Wright,  Hamilton :  ' '  The  Action  of  Ether  and  Chloroform  on  the  Neurons 
of  Rabbits  and  Dogs,"  J.  Physiol,  1900-1,  26,  30,  362. 


GENERAL  PHYSIOLOGY  OF  INHALATION  ANESTHESIA      41 

whether  chloroform  and  ctlicr  produce  any  transient  or  permanent 
changes  in  the  cortical  or  spinal  neurons. 

In  rabbits  he  found  that  these  agents  produced  changes  in  the  nerve 
cells  of  both  the  brain  and  spinal  cord.  These  changes  were  slight  at  first, 
but  became  more  marked  as  the  anesthesia  continued.  The  principal 
change  was  described  by  him  as  "rarefaction."  In  the  advanced  cases 
he  employed  the  term  "skeleton  cell,"  and,  in  the  most  marked  cases, 
he  found  that  a  "pseudo-degenerative"  change  had  set  in. 

In  dogs  there  were  practically  no  changes  up  to  two  hours,  but, 
between  that  time  and  tour  hours,  changes  occurred  in  the  nerve  cells 
similar  in  kind  to  those  observed  in  rabbits,  although  less  in  degree. 
These  changes  became  more  marked  as  the  anesthetic  was  continued. 

Wright  regarded  the  changes  observed  in  the  cells  and  their  pro- 
cesses as  due  directly  to  the  influence  of  the  anesthetic,  and  not  due  indi- 
rectly to  the  capillary  anemia  which  is  produced. 

Inasmuch  as  it  is  generally  conceded  that  ether  and  chloroform  cir- 
culate in  the  blood  as  such,  producing  no  biochemical  changes  in  the 
blood,  Wright  concluded  that  the  neuronal  changes  are  hiocheraical 
in  nature,  and  are  'produced  by  the  anesthetic  that  readies  them  via  the 
blood  stream. 

There  is  nothing,  he  holds,  to  suggest  that  chloroform  or  ether  could 
cause  these  changes  mechanically;  the  supposition  that  they  act  chem- 
ically is  extremely  probable. 

It  is  obviously  impossible  to  say  that  these  changes  occur  in  human 
beings.  Wright  did  not  consider,  however,  that  there  is  any  analogy 
between  the  changes  described  and  those  biochemical  anabolic  and 
katabolic  changes  that  occur  in  daily  life,  and  mark  sleeping  and  waking 
hours.  He  regarded  the  action  of  narcotics,  such  as  ether  and  chloro- 
form, as  pathological,  not  very  intensely  so,  yet  as  something  which  is 
remote  from  physiological  processes.  In  sleep  there  is  probably  an 
opportunity,  he  says,  for  the  constituents  of  the  nerve  cells  to  undergo 
anabolic  changes,  whereas  in  the  unconsciousness  produced  by  anes- 
thetics the  process  appears  to  be  associated  with  an  exhaustion  of  them. 

A  subsequent  series  of  experiments^  was  undertaken  (1)  to  determine 
whether  a  still  more  prolonged  period  of  anesthesia  renders  the  changes 
more  intense,  and  (2)  to  ascertain  whether  the  pseudo-degenerative 
change  is  permanent:  the  answer  to  the  first  question  was  affirmative; 
to  the  second,  negative. 

In  the  cases  in  which  the  anesthesia  was  kept  up  longest  it  was 
found  that  even  the  nuclei  and  the  nucleoli  were  afl^ected,  the  latter 
being  the  last  part  of  the  cell  to  show  the  effect  of  the  drugs.  The 
slow  return  of  the  conjunctival  reflex  in  these  cases,  he  thought,  indi- 
cated that  after  a  certain  period  of  anesthesia   (six  hours  in  the  dog) 

^Wright:     /feid.,  page  363. 


42  ANESTHESIA 

the  depression  of  neuronal  function  becomes  more  rapidly  profound, 
and  that  there  is  a  limit  to  the  time  of  safe  anesthesia.  The  histological 
changes  observed  induced  this  view.  A  greater  alteration  occurred  in 
the  cells  during  the  three  hours  between  the  sixth  and  the  ninth  hours 
of  anesthesia  than  during  the  five  hours  between  the  first  and  the  sixth 
hours. 

The  changes  observed  in  the  cells  were  transitory,  disappearing  with 
the  disappearance  of  the  drugs  from  the  circulation  and  tissues,  or  soon 
thereafter.  Forty-eight  hours  after  nine  hours  of  ether  narcosis  the  cells 
were  found  to  be  practically 'normal. 

The  rarefaction  of  the  cell  substance  and  the  formation  of  monili- 
form  (necklace-like)  swelling  noted  in  the  dendrons,  according  to 
Wright,  may  modify  nervous  function.  "To  such  changes,"  he  says, 
"may  perhaps  be  attributed  those  losses  of  memory,  slight  manias  and 
melancholias  that  are  now  and  then  reported  to  follow  prolonged  anes- 
thesia in  the  human  subject.^' 

Traube's  Theory.^ — In  his  theory  of  the  production  of  general  anes- 
thesia, Traube  contradicts  the  lipoid  solubility,  claimed  by  Overton, 
as  the  primary  cause  of  the  penetration  of  the  anesthetic  agent  into 
the  cell.  This  cause,  according  to  Traube,  consists  in  the  surface  ten- 
sion. When  two  fluids  of  different  surface  tension  are  separated  through 
a  membrane,  the  fluid  having  the  lower  tension  can  find  its  way  to  that 
Avith  the  higher  tension;  so  that  the  difference  between  the  surface 
tensions  explains  the  entrance  of  the  anesthetizing  fluid  into  the  cells.- 
He  also  claims  the  existence  of  a  close  conformity  between  the  narcotic 
efficiency  and  the  surface  tension  in  the  case  of  'pure  anesthetic  agents 
which  are  free  from  toxic  side-effects. 

Mathews-Brown  Theory. — Mathews  ^  made  Nef's  bivalent  carbon 
hypothesis  *  the  basis  of  a  hypothesis  for  protoplasmic  respiration  which 

^Traube:  "Theorie  der  Osmose  und  Narkose, "  Arch.  ges.  Physiol.,  1904, 
105,  451;  Phil.  Mag.   (6),  8,  704;  Z.  physiol.  Chem.,  JOS,  541. 

-  When  the  drug  has  thus  gained  entrance  to  the  cell,  it  may  exercise  its 
narcotic  power  in  proportion  to  its  solubility  in  the  cell  lipoids. 

^  Mathews,  A.  P. :    Biol.  Bull,  1905,  8,  331. 

*  The  bivalent  carbon  hypothesis  of  Nef  (J.  Am.  Chem.  Soc,  26,  1549)  ap- 
proaches the  action  of  narcotic  agents  to  the  fundamental  reactions  of  organic 
chemistry.  According  to  his  investigations  of  the  chemistry  of  the  element  car- 
bon, protoplasmic  respiration  can  be  explained  as  a  vital  reaction  through  the 
decomposition  of  water,  on  the  basis  of  a  change  in  valence  of  the  carbon  atom 
from  four  to  two.  The  quadrivalence  of  carbon  is  not  constant,  the  existence 
of  carbon  compounds  containing  bivalent  carbon  having  been  definitely  estab- 
lished. The  bivalent  carbon  compound  of  cells,  or  their  respiratory  elements, 
are  the  point  of  attack  of  the  entering  anesthetic  agent.  The  action  is  assisted 
by  a  rise  in  temperature.  Substances  which  are  perfectly  indifferent  chemi- 
cally, such  as  the  volatile  saturated  hydrocarbons,  may  produce  anesthesia  by 
entering  into  a  loose  chemico-physical  combination  with  certain  cell  constituents. 


GENERAL  PHYSIOLOGY  OF  INHALATION  ANESTHESIA     43 

Brown  ^  considers  plausible.  The  bivalent  carbon  compound  of  the  pro- 
toplasm, luliich,  according  to  Mathews,  may  be  either  simple  or  complex, 
decomposes  the  water  of  the  tissues  into  its  elements.  The  oxygen,  com- 
bining ivith  the  compounds  constituting  protoplasm,  oxidizes  them.  The 
hydrogen,  uniting  with  free  oxygen  or  other  substance  in  the  tissues, 
passes  off  as  gas. 

Mathews  holds  that  anesthetics  inhibit  the  action  of  the  bivalent 
carbon,  thereby  decreasing  the  respiration  of  the  cell  protoplasm,  result- 
ing in  the  stage  known  as  anesthesia. 

Brown,  referring  to  this  theory,  thought  it  more  likely  that  the  sub- 
stances producing  a  narcosis  do  so,  "not  by  an  action  on  any  one  of  the 
essential  processes  of  the  protoplasm,  but  from  the  combined  influence 
of  all  of  them.  The  role  that  the  lipoids  of  the  cell  play  in  narcosis  may 
be  only  that  of  a  solvent  or  gatherer  for  the  narcotic,  or  more,  depending 
upon  whether  or  not  the  lipoid  is  concerned  with  the  essential  living 
processes  of  the  cell." 

Mathews  had  previously  called  Brown's  attention  to  the  fact  that 
starfish  eggs  were  greatly  affected  by  chloroform,  ether,  etc.  The  efl'ect 
appeared  to  be  a  partial  liquefaction  of  the  protoplasm.  Mathews  sug- 
gested that  possibly  the  power  of  each  member  of  this  group  of  com- 
pounds to  liquefy  the  starfish  eggs  might  be  proportional  to  its  narcotic 
power.  Mathews  had  made  some  experiments  along  this  line,  a  report 
of  which  was  published.  This  work  was  repeated  and  extended  by 
Brown,  who  made  a  comparative  study  of  a  number  of  the  compounds  in 
common  use  as  anesthetics,  narcotics  and  hypnotics. 

The  change  produced  in  the  eggs  was  found  to  be  a  profound  one. 
The  eggs  enlarged  and  became  lighter  in  color;  the  protoplasm  became 
less  granular,  and  finally  there  was  a  rupture  of  the  envelope  at  some 
spot,  the  contents  flowing  out. 

Brown  called  attention,  in  this  connection,  to  Hermann's  ^  observa- 
tion of  a  similar  change  in  red  blood  corpuscles  when  treated  with  an- 
esthetics. The  process  indicated  that  the  contents  of  the  cell  had  been 
increased,  in  amount  and  fluidity.  The  explanation,  according  to 
Brown,  seems  to  be  that  the  narcotics  are  taken  up  by  the  fat-like  bodies 
of  the  egg. 

From  his  comparative  studies  Brown  concluded,  in  part,  as  follows : 

"(1)  That  anesthetics  and  narcotics,  at  certain  concentrations,  cause 
a  profound  change  in  the  eggs  of  starfish.  This  change  appears  to  be  a 
the  effect  disappearing  as  soon  as  this  loose  reversible  combination  ceases. 
From  this  point  of  view,  narcosis  represents  an  inhibition  of  the  entire  chemism 
of  the  nerve  cell,  through  changes  in  the  normal  mutual  relations  of  the  cell 
constituents. 

^  Brown,  Orville  Harry :  "A  Pharmacological  Study  of  Anesthetics  and 
Narcotics,"  Am.  J.  Physiol,  1905-6,  15,  85. 

=" Hermann:     Arch.  Anat.  Physiol.,  Wes.  Med.,  1866,  27. 


44  ANESTHESIA 

partial  liquefaction.  The  power  of  the  compounds  in  bringing  this  about 
is  indicative  of  their  power  as  narcotics;  i.  e.,  the  narcotic  substance 
which  produces  liquefaction  of  the  eggs  in  a  dilute  solution  will  also, 
in  small  amounts,  produce  narcosis. 

"(2)  That  anesthetics  and  narcotics  do  not  cause  the  liquefaction  if 
they  are  sufficiently  concentrated  or  sufficiently  diluted.  The  concen- 
trated solution  causes  a  change  which  has  the  appearance  of  a  coagu- 
lation. 

"(3)  The  most  important  role  of  the  lipoids  in  bringing  about  anes- 
thesia probably  is  one  of  accumulation.  If  they  are  concerned  with  the 
essential  process  of  the  cell,  then  their  part  is  most  likely  a  broader  one. 

"(4)  Anesthesia  is  very  possibly  the  result  of  an  inhibition,  by  the 
compounds,  of  the  enzymotic  processes  of  the  cell,  as  suggested  by 
ISTeilson  and  Terry.^ 

"(5)  Mathews'  idea  that  the  anesthetics  produce  their  results  by  their 
influence  upon  the  respiratory  elements — the  bivalent  carbon  compound 
— of  the  cell  is  a  tenable  one. 

"(6)  Nef's  bivalent  carbon  hypothesis  may  help  to  explain  the  more 
rapid  narcosis  when  the  temperature  is  slightly  raised." 

Moore-Roaf  Theory.- — Moore  and  Eoaf  have  found  that  the  action  of 
the  numerous  substances  used  as  anesthetics  probably  depends  on  the 
general  type  of  interaction  between  it  and  the  cell  protoplasm.  In 
regard  to  chloroform,  they  pointed  out  that  attention  was  not  restricted 
to  the  action  on  nervous  structures,  since  all  cells  (bacteria,  amebse, 
ciliated  cells,  etc.)  are  equally  affected.  It  was  therefore  concluded 
that  the  action  must  take  place  with  some  chemical  constituent  present 
in  all  varieties  of  protoplasm,  and  that  theories  based  on  the  high  con- 
tent of  nerve  cells  in  lecithin  and  fatty  constituents  may  be  disregarded. 
Proteid  is  the  substance  of  all  others  universally  present  in  all  cells, 
and  Moore  and  Eoaf  found  that  chloroform  formed  loose  compounds 
with  many  proteids ;  in  fact,  that  it  would  precipitate  them  if  in  excess.^ 
This,  they  thought,  explains  the  greater  solubility  of  chloroform  in  the 
blood,  or  in  serum  and  hemoglobin  solutions,  than  in  water  or  in  saline 
solutions. 

Their  theory  of  narcosis  may  thus  be  expressed:  The  loose  com- 
pound of  proteid-cMoroform  is  similar  to  oxyhemoglobin.  When  anes- 
thesia occurs,  the  proteid-cliloroform  compound  of  the  blood  has  parted 
with  its  chloroform  to  the  cell  proteids;  the  compound  here  formed 
undergoes   dissociation   when   the   chloroform   pressure   is   reduced   on 

^JMeilson  and  Terry:     Am.  J.  Physiol.,  1905,  14,  248. 

'  Moore  and  Eoaf :     Proc.  Boy.  Soc,  73,  382. 

^  Formanek  (Z.  pliysiol,  CJiem.,  29,  416)  has  also  found  that  both  chloroform 
and  chloral  hydrate  are  good  precipitants  of  the  blood  pigment,  particularly  at 
56°  C.     He  recognized  that  chloroform  is  a  precipitant  for  proteids. 


GENERAL  PHYSIOLOGY  OF  INHALATION  ANESTHESIA      45 

cessation  of  administering  the  aneslhelic,  and  anesthesia  tlius 
ceases. 

Later,  Moore  and  Eoaf  ^  supplied  confirmation  to  the  theory  that 
chloroform  and  other  anesthetics  form  unstable  compounds  with  pro- 
teids,  and  that  they  produce  their  effects  by  thus  interfering  with  the 
chemical  activities  of  protoplasm.  They  learned  that  the  solubility  of 
the  anesthetic  was  greater  in  serum  than  in  water,  and  that  beyond  a 
certain  concentration,  which  was  definite  for  each  anesthetic,  precipi- 
tation of  the  compound  with  proteid  occurred.  It  was  found  that  the 
vapor  pressure  was  always  higher  in  an  aqueous  solution  than  in  solu- 
tions which  contained  j)roteid,  and  determinations  of  freezing  points 
and  electrical  conductivity  supported  the  main  contention  of  the  inves- 
tigators.^ 

Edie  ^  investigated  the  proteids  of  serum  and  hemoglobin  in  ref- 
erence to  the  work  of  Moore  and  Eoaf.  It  was  found  that  the  compound 
of  chloroform  and  hemoglobin  was  less  stable  than  carboxy-hemoglobin, 
and  that  when  sufficient  chloroform  was  added  to  produce  precipitation 
the  amount  of  chloroform  found  in  the  precipitate  was  constant.  In 
the  case  of  the  serum  proteids,  also,  the  amount  of  chloroform  was  found 
to  be  fairly  constant. 

The  action  of  chloroform  and  hemoglobin  has  also  been  studied  by 
Kriiger,*  whose  experiments  showed  that  chloroform  was  not  an  indif- 
ferent reagent  toward  hemoglobin,  but  that  it  changed  it  into  a  more 
insoluble  modification  without  apparently  producing  any  profound 
chemical  alteration. 

The  following  determined  facts  seem  to  lend  the  theory  of  Moore 
and  Eoaf  additional  support: 

( 1 )  It  has  been  shown  by  Carlson  and  Luckhardt  ^  that  during 
chloroform  or  ether  anesthesia  the  osmotic  concentration  of  the  blood 
rises.  This  varies  with  the  depth,  and  not  with  the  duration,  of  the 
anesthesia.  The  main  factor  in  this  observation  ap]3ears  to  be  that  the 
ether  or  chloroform  itself  is  dissolved  in  the  blood,  although  there  are 
other  factors  which  cannot  be  altogether  excluded. 

(2)  Camus  and  Nicloux ''  have  found  that  ethyl  chlorid  is  taken  up 
by  the  blood  with  great  rapidity  and  is  also  eliminated  with  rapidity. 

(3)  Livon  ^  found  that  during  anesthesia  produced  in  dogs  by  amy- 

'  Moore  and  Eoaf:    Proc.  Eoy.  Soc,  B.,  77,  86. 

'■'Thompson,  Yates,  and  Johnston,  Lah.  Report,  Liverpool,  1905-6,  151-94;  and 
ef.  the  investigations  of  Buglia  and  Simon:     Arch.  ital.  hiol.,  48,  1. 

"  Thompson,  Yates,  and  Johnston,  Lah.  Beport,  Liverpool,  1905,  6,  195. 

*Beitr.  chem.  Physiol.  Path.,  3,  67.  Cf.  Gianasso:  Eiforma  Medica,  22  No.  19, 
who  is  of  the  opinion  that  chloroform  destroys  the  red  corpuscles  of  the  blood. 

^  Compt.  rend.  Soc.  hiol.,  55,  143. 

"  Ihid.,  145,  1437. 

'  lUd.,  55,  143. 


46  ANESTHESIA 

lene  there  is  no  arrest  of  internal  combustion;  but;,  on  extracting  the 
blood  gases,  amylene  was  found  as  a  constituent. 

Gill's  Theory.^— Gill's  observations  concerned  chloroform,  which,  ac- 
cording to  his  theory,  abstracts  oxygen  from  the  blood,  being  itself 
destroyed  in  the  process.  "The  deoxygenation  factor,"  according  to 
Gill,  "which  is  their  proximate  cause,  thus  intermediates  between  the 
indirect  phenomena  and  their  ultimate  cause,  which  is  chloroform." 
The  relation  between  chloroform  and  the  blood  is  held  by  him  to  be 
twofold.  It  causes  deoxygenation  by  the  diminishment  of  the  normal 
supply  of  air  to  the  alveoli  of  the  lungs,  and  by  its  physiologico-chem- 
ical  action  it  is  indirectly  the  cause  of  the  suspension  of  the  functions 
of  the  cerebral  centers. 

Hober's  Theory.^ — In  his  studies  on  the  physical  chemistry  of  excita- 
tion (of  muscle)  and  of  narcosis,  Hober  found  that  isotonic  solutions 
of  normal  salts  of  the  alkali  metals  produce  currents  of  rest  of  varying 
intensity  and  direction  when  applied  locally  to  the  non-injured  sartorius 
muscle  of  the  frog.  When  arranged  according  to  their  power  of  pro- 
ducing this  current,  the  various  anions  and  cations  form  two  series, 
which  coincide  with  those  which  have  been  deduced  from  their  action  on 
the  solubility  of  egg-white  and  of  lecithin.^  This  coincidence  is  one 
of  the  reasons  for  Hober's  conclusion  that  excitation  and  the  electrical 
reaction  accompanying  it  are  closely  connected  with  the  consistency  of 
the  muscle  colloids. 

According  to  Hober,  narcotics  inhibit  the  change  in  the  colloids  (of 
the  axis  cylinder),  which  change  accompanies  the  normal  current  of 
action,  and,  in  accordance  with  the  current  theory  of  narcosis,  due  to 
Meyer  and  Overton,  this  colloidal  change  is  supposed  to  occur  in  the 
lecithin.  Narcosis  would  therefore  consist,  first,  in  the  accumulation 
of  the  lipoid-soluble  narcotic  in  the  lipoid  substance  (lecithin),  and, 
second,  in  the  inhibition  of  the  colloidal  changes  which  excitation  nor- 
mally produces  in  this  substance. 

Baglioni's  Theory.* — Baglioni  maintains  that  narcotic  effect  depends 

^Gill,  Eichard:     "The  CHCI3  Problems,"  1906,  2,  Physiological  Action. 

"Pfliiger's  Archiv,  1907,  ISO,  492;  /.  Chem.  Soc,  94,  ii,  121. 

^  An  examination  of  the  effect  of  normal  salts  on  the  precipitation  of  egg- 
albumen,  serum-albumin,  and  lecithin,  and  on  the  catalysis  of  methyl  and  ethyl 
acetates  by  acid  and  by  alkali,  was  made  by  Hober  (Beitr.  chem.  Physiol.  Path., 
11,  35).  The  results  obtained  by  catalysis  were  quite  regular;  for  instance,  the 
chlorids  of  the  alkali  metals  accelerated  the  acid  catalysis  in  the  order  of  their 
atomic  weights,  lithium  chlorid  being  most,  and  caesium  chlorid  least,  active. 
In  neutral  solutions,  the  order  of  efficiency  as  precipitants  became  irregular,  and 
depended  simultaneously  on  both  ions. 

On  the  efficiency  of  various  salts  of  the  alkali  metals  as  lecithin  precipitants, 
see  also  Porges  and  Neubauer:     Biochem,  Z.,  7,  152. 

*  Francis  and  Fortescue-Brickdale :  "The  Chemical  Basis  of  Pharmacology," 
1908,  86. 


GENERAL  PHYSIOLOGY  OF  INHALATION  ANESTHESIA      47 

on  the  deprivation  of  oxygen  from  the  "inogen"  compounds  in  the 
central  nervous  system;  narcosis  is  a  reducing  process.  This  theory  is 
based  on  the  fact  that,  in  the  case  of  various  groups  of  benzenephenol 
derivatives,  the  paralyzing  action  of  the  substance  is  inversely  propor- 
tional to  the  amount  of  oxygen  already  in  the  side-chain,  and  that 
deprivation  of  oxygen  by  breathing  inert  gases,  as  carbon  dioxid  or 
hydrogen,  produces  symptoms  similar  to  those  of  chloroform.  Support 
to  the  view  is  had  from  the  work  of  Herter,^  who  showed  that  chloro- 
form, ether,  and  chloral  hydrate  diminish  the  oxidizing  capacity  of 
tissues.  The  theory  of  Baglioni  indicates  a  possible  mode  of  the  action 
of  narcotics  after  they  have  entered  the  cell.  The  other  theories  mainly 
pertain  to  the  conditions  which  determine  entrance  into  the  cell 
substance. 

Reicher's  Theory.^ — Beicher  carried  out  a  series  of  experimental 
studies  on  anesthetized  dogs,  in  which  he  invariably  found  a  considera- 
ble increase  of  the  fat,  or  the  lipoids,  in  the  circulating  blood.  From 
this  he  drew  the  conclusion  that  the  narcotic  effect  is  not  due  to  the 
fixation  of  the  anesthetic  in  the  lipoids  of  the  brain,  but  rather  to  the 
ivashing  out  of  the  lipoids  from  the  brain.  The  Meyer-Overton  theory 
should  accordingly  be  revised.  Through  the  lipemia  there  occurs  a 
profound  impairment  of  the  fat  metabolism,  which,  in  its  turn,  leads 
to  acetone  intoxication.^  Again,  the  acetone  intoxication  explains  a 
part  of  the  fundamental  disturbances  of  the  nervous  system  produced 
by  the  general  anesthesia. 

The  modification  of  the  Meyer-Overton  theory,  as  proposed  by 
Eeicher  on  the  basis  of  his  findings,  is  as  follows:  The  decisive  factor 
for  the  efficiency  of  an  anesthetic  consists  in  its  relative  solubility 
in  the  lipoids.  There  takes  place  not  simply  a  change  of  the  normal 
physical  condition,  not  merely  a  fixation  in  a  sort  of  rigid  solution, 
without  the  extrusion  of  lipoids  from  the  cell;  there  occurs  also  an 
expulsion  of  vital  lipoids  and  fats,  in  an  as  yet  unknown  mutual 
action  between  the  anesthetic  agent  and  the  cell  lipoids,  this  inter- 
action perhaps  playing  a  part  in  the  occurrence  of  the  general  anes- 
thesia; the  lipoid  remains  for  a  long  time  chemically  and  microscopically 
demonstrable  in  the  blood,  as  well  as  histologically  demonstrable  in  the 
organs. 

Kramer's  *  experiments  do  not  bear  out  Reicher's  assmnption  as 
to   the   cause   of  the  lipemia.      The   explanation   of  this   phenomenon, 

^  Herter  and  Eichards:  Am,  J.  Physiol.,  12,  207.  See  also  Wright:  J. 
Physiol,  26,  362. 

^  Eeicher,  K. :  "  Chemisch-experimentelle  Studien  zur  Kenntniss  der  ISTark- 
ose,"  Zeitschr.  Min.  Med.,  1908,  65,  235. 

^  These  results  refer  to  aliphatic  derivatives. 

* ' '  The  Eole  of  the  Lipoids  and  Particularly  Lecithin  iu  Narcosis, ' '  J.  Exper. 
Med.,  1913,  17,  No.  2. 


48  •  ANESTHESIA 

according  to  Kramer,  is  still  an  open  question,  for  from  his  observations 
he  concluded: 

"1.  The  intravenous  injection  of  five  to  thirty  cubic  centimeters  of 
a  5  or  10  per  cent  emulsion  of  lecithin,  depending  upon  the  size  of  the 
animal  used,  does  not  interfere  with  the  induction  of  anesthesia,  and 
this  can  be  accomplished  as  readily  in  animals  thus  injected  as  in 
controls. 

"2.  In  six  out  of  nine  experiments  lecithin  had  no  effect  upon  the 
rapidity  with  which  the  various  phenomena  which  indicate  the  animal's 
recovery  from  the  efEects  of  the  anesthetic  appeared."' 

Gros's  Conclusions.^ — -Gros's  experimental  investigations  of  the  rela- 
tionship of  general  and  local  anesthetics,  on  the  basis  of  physical  chem- 
istry, show  that  the  latter  have,  in  many  respects,  the  same  properties 
and  effects  as  the  former.  General  anesthetics  possess  the  following 
three  properties :  ^ 

(1)  A  general  action  on  protoplasm. 

(2)  An  elective  action  upon  the  nervous  system,  especially  the 
central  nervous  system. 

(3)  The  possibility  of  restitution  of  the  functions  which  have  been 
disturbed  by  the  anesthetic  agent. 

Biirker's  Theory.^ — According  to  Biirker,  anesthesia  is  produced  in 
such  a  way  that,  in  the  first  place,  the  anesthetic  agent  accumulates 
especially  in  the  nervous  system,  on  account  of  its  marked  lipoid  solu- 
bility. This  accumulation,  as  such,  does  not  suffice,  but  a  chemical 
reaction  results,  the  anesthetic  agent  appropriating  the  active  oxygen. 
In  consequence,  this  substance  is  withdrawn  from  the  nervous  tissue 
which  is  so  arid  of  oxygen,  and  this  oxygen  deprivation  leads  to  tem- 
porary asphyxiation,  with  paralysis  of  the  physiological  function.  The 
products  which  originate  in  the  oxidation  of  the  anesthetic  agent  may 
be  considered  as  partially  responsible  for  the  untoward  after-effects  of 
general  anesthesia. 

This  theory  is  based  upon  the  following  observation,  as  well  as  upon 

'  Gros,  O. :  "Ueber  Narkotika  und  Lokalanesthetika, "  Arch.  exp.  Path.  u. 
Pharm.,  1910,  63,  80. 

^  These  three  properties  are  likewise  found  in  the  local  anesthetics,  cocain, 
encain,  stovain,  alypin  and  novocain,  which  are  protoplasmic  poisons.  The 
more  strongly  a  general  anesthetic  acts  upon  the  central  nervous  system,  the 
stronger  is  its  action  also  as  a  local  anesthetic. 

The  theory  of  Meyer  and  Overton  is  also  applicable  to  local  anesthetics.  As 
compared  to  general  anesthetics,  the  local  agents  show  the  important  difference 
that  the  sensory  nervous  system  is  more  sensitive  toward  them,  in  a  general  way, 
than  the  motor  nervous  system. 

The  anesthetic  potential  of  the  local  anesthetic  palt  depends  on  that  of  the 
base  and  the  degree  of  hydrolytic  dissociation. 

^Biirker:  "Eine  neue  Theorie  der  Narkose, "  Centralbl.  Physiol.,  1911,  S4, 
103;  Munch,  med.  Woch.,  1910,  27,  1445. 


GENERAL  PHYSIOLOGY  OF  INHALATION  ANESTHESIA     49 

certain  other  well-known  facts:  When  an  electric  current  is  passed 
through  acidulated  water,  saturated  with  ether  or  some  other  anesthetic 
agent,  only  a  very  small  amount  of  oxygen  is  liberated  at  the  anode,  the 
remaining  oxygen  being  utilized  for  the  oxidation  of  the  ether,  with 
the  production  of  carbon  monoxid,  carbonic  acid,  acetaldehyd,  etc. 
Biirker's  experiments,  in  his  opinion,  are  promising  in  regard  to  the 
rational  selection  of  the  anesthetic  agents  by  means  of  electrolysis;  and, 
at  the  same  time,  they  elucidate  the  character  of  the  oxidation  processes 
in  the  living  substance.    It  is  also  noteworthy,  in  this  connection,  that  a 

—  solution  of  grape-sugar  (1.8  per  cent)  has  practically  no  influ- 
ence upon  the  course  of  the  electrolysis,  in  acid  and  neutral  solutions, 
showing  that  the  active  oxygen  alone  is  evidently  insufficient  for  its  com- 
plete combustion. 

The  chemical  indifference  of  the  anesthetic  agents,  or  a  purely 
mechanical  change  in  the  condition  of  the  plasma  colloids,  in  the  sense 
of  Meyer  and  Overton,  can  hardly  be  admitted,  according  to  Biirker, 
whose  experiments  indicate  a  temporary  asphyxiation  of  the  nervous 
system,  in  general  anesthesia  in  the  sense  of  Verworn  and  his  school. 
The  mechanism  of  this  asphyxiation  is  suggested  by  the  results  of  the 
-electrolytic  experiments.  The  bad  after-effects  of  general  anesthesia 
are  accounted  for  by  the  changed  metabolism  in  general,  which  would 
be  entirely  inexplicable  in  the  case  of  a  chemical  indifference  of  the  anes- 
thetic agent.  The  metabolism  is  altered  in  a  similar  way  as  in  diabetes, 
a  disturbance  of  the  normal  oxidation  processes  being  probably  respon- 
sible. 

Verworn's  Theory.^ — Verworn,  in  his  recent  monograph,  contributes 
the  result  of  his  investigations,  after  ten  years'  work  on  the  elucidation 
of  the  mechanism  of  anesthetics  by  means  of  experiments.  On  the  basis 
of  his  findings,  he  groups  anesthesia  under  the  headings  of  the  manifold 
paralyses  which  originate  through  a  disturbance  of  the  oxygen  metahol- 
ism.  General  anesthesia  is  equivalent  to  asphyxiation  of  the  tissues. 
This  asphyctic  state  does  not  occur  in  consequence  of  the  deficiency  in 
oxygen  as  such,  but  it  arises  through  the  inhibition  of  the  oxidation 
processes  by  the  anesthetic  agents.  Accordingly,  asphyxiation  may  also 
occur  in  the  presence  of  abundant  oxygen  contents  of  the  medium  in  the 
surroundings  of  the  tissue  or  of  the  tissues  themselves.  In  asphyxiation 
through  the  anesthetic  the  paralysis  is  acute;  in  asphyxiation  in  a 
medium  free  from  oxygen  the  paralysis  is  more  gradual  in  onset. 

In  discussing  the  potential  fashions  in  which  the  anesthetic,  by  pene- 
trating into  the  cell,  suppresses  its  capacity  for  the  production  of  oxida- 
tions, Verworn  inclines  to  the  explanation  that  the  anesthetic  agent  pre- 
vents the  transmission  of  oxygen  from  the  medium  and  the  reserve  stores 
^Verworn,  M. :     "Narkose"    (Monograph),  Jena,  1912. 


50  •  ANESTHESIA 

in  the  cell  to  the  oxidizing  materials.  This  explanation  is  most  readily 
compatible  with  the  laws  of  lipoid  solubility  and  anesthetic  action,  for- 
mulated by  Meyer  and  Overton;  in  this  connection,  Verworn  assumes 
that  the  lipoids  are  in  some  way  closely  related  to  the  oxygen  carriers. 

In  conclusion,  the  author  explains  the  difference  between  sleep  and 
general  anesthesia :  In  sleep,  a  reaction  takes  place,  with  the  assistance 
of  the  oxygen ;  whereas,  in  general  anesthesia,  the  restitution  is  inhibited 
through  the  prevention  of  the  oxygen  of  the  oxidation  processes.  Hence, 
these  processes  are  radically  different. 

Commenting  on  the  view  of  Verworn,  Lillie  ^  points  out  that  "cell- 
division — e.  g.,  in  developing  egg-cells^usually  ceases  if  the  oxygen  sup- 
ply is  insufficient.  Contractile  activities  are  decreased  or  abolished. 
Many  organisms,  however,  show  only  slight  immediate  effects;  this  is 
true  of  many  Protozoa;  Vorticellse,  for  instance,  remain  contractile  for 
some  time  after  simple  removal  of  oxygen  from  the  medium,  although 
they  are  at  once  paralyzed  by  anesthetics.  "Such  facts  oppose  the  view 
held  by  Verworn  and  others,  that  the  anesthetic  acts  primarily  on  the 
oxidative  mechanism  of  the  cell.  It  is  true  that  the  rate  of  oxidation 
in  active  tissues  is  lowered  during  anesthesia,  but  this  effect  is  rather  a 
consequence  than  a  cause  of  the  lessened  activity.  Obviously  wherever 
free  oxygen  is  necessary  to  the  normal  activities  of  a  tissue  its  withdrawal 
will  arrest  those  activities.  But  the  effects  produced  by  lack  of  oxygen 
are  not  to  be  identified  with  anesthesia  because  of  such  incidental  resem- 
blances." 

The  Conclusions  of  Lillie."— Lillie  has  indicated  that  under  certain 
well-defined  artificial  conditions,  as  well  as  under  some  that  are  normal, 
"the  living  system — organism,  tissue  or  cell — becomes  temporarily  in- 
active and  irresponsive  to  stimuli.  When  such  an  artificially  induced 
state  of  inhibition  is  well  marked  and  lasting  it  is  called  anesthesia,  or, 
in  a  somewhat  more  restricted  sense,  narcosis.  This  condition  may  last 
for  hours  or  even  days,  but  apparently  not  indefinitely;  and,  when  it 
passes  off,  the  normal  vital  activities  and  properties  return  unimpaired. 
This  apparently  complete  reversibility  is  one  of  the  most  remarkable 
features  of  anesthesia,  and  distinguishes  it  from  death — a  perhaps  re- 
lated but  characteristically  irreversible  change.  The  terms  'anesthesia' 
and  'narcosis'  are  somewhat  differently  applied,  although  they  have 
the  same  essential  significance;  the  former  relates  to  any  temporarily 
insensitive  condition,  however  produced,  while  'narcosis'  usually  means 
an  anesthesia  produced  by  chemical  substances." 

Lillie  used  the  term  anesthesia  to  designate  "any  temporary  or  rever- 
sible lowering  or  loss  of  the  normal  vital  responsiveness,  or  of  the  normal 
automatic  vital  activity,  under  the  influence  of  certain  artificial  suh- 

^  Science,  n.  s.,  37,  959. 
'Ibid.,  Nos.  965,  959-972. 


GENERAL  PHYSIOLOGY  OF  INHALATION  ANESTHESIA      51 

stances  or  conditions.  Anesthesia,  as  thus  defined,  may  be  exhibited  by 
the  most  various  organisms  and  cells,  if  not  by  all.  It  is  fully  as  charac- 
teristic of  plant  cells  as  of  animal  cells,  although  its  manifestations  may 
be  less  obvious  and  striking  in  the  former  group  of  organisms.  In  its 
most  familiar  aspect  the  complete  organism,  e.  g.,  a  man,  or  an  isolated 
living  tissue,  as  a  nerve  or  muscle,  fails  during  anesthesia  to  show  any 
response  to  a  stimulus  which  normally  excites  it  strongly.  In  other 
words,  the  capability  of  responding  to  stimuli — what  we  call  'irritabil- 
ity'— is  in  anesthesia  diminished  or  lost.  When  the  condition  passes  off 
the  normal  responsiveness  returns  unimpaired."  ^ 

However,  such  decrease  of  the  vital  activity  or  responsiveness  is  not 
a  solely  artificial  phenomenon.  Conditions  physiologically  resembling 
anesthesia  occur  normally  in  the  life  of  many  organisms;  sleep  is,  for 
example,  a  variety  of  physiological,  regularly  recurring  narcosis,  and  all 
irritable  tissues  lose  their  responsiveness  for  a  brief  period  following 
excitation.  The  last-mentioned  state,  the  so-called  "refractory  period," 
has  been  compared  with  narcosis  by  some  physiologists.  There  are  also 
noteworthy  resemblances  between  narcosis  and  fatigue.  Thus  the  degree 
of  irritability  of  a  tissue  may  vary  within  a  wide  range  under  normal  as 
well  as  artificial  conditions. 

Lillie  calls  attention  to  a  number  of  physical  conditions  which  may 
deprive  a  cell  temporarily  of  irritability;  for  example,  mechanical  shock 
and  electrical  currents  may  have  this  effect.^ 

^ ' '  Thus  a  muscle  exposed  to  ether  vapor  soon  ceases  to  contract  on  stimula- 
tion; under  the  same  conditions  a  nerv^e  ceases  to  conduct;  in  motile  plants  like 
sensitive  plants  the  characteristic  osmotic  jnoloi-mechanisms  cease  to  act.  Auto- 
matic activities  like  ameboid  movement,  ciliary  movement,  protoplasmic  flowing, 
cell  division,  and  growth  may  also  be  brought  temporarily  to  a  rest  by  anes- 
thetics. Claude  Bernard  showed  that  seedlings  ceased  growth  in  an  ether-im- 
pregnated atmosphere,  and  resumed  it  when  the  ether  was  removed.  Fertilized 
egg-cells  cease  to  divide  in  the  presence  of  an  anesthetic  in  appropriate  concen- 
tration, although  they  remain  living  and  proceed  with  cell-division  and  develop- 
ment when  the  anesthetic  is  removed.  Other  less  evident  cell-processes,  includ- 
ing metabolism,  are  similarly  affected;  the  rate  of  oxidation  is  usually  dimin- 
ished during  anesthesia  though  there  are  exceptions  to  this  rule. ' ' 

' ' '  Under  certain  conditions  the  elect^-ie  current  may  produce  effects  closely 
resembling  typical  anesthesia.  (See  Chapter  XVI,  p.  628.)  This  occurs  when 
a  weak  constant  current  is  passed  through  an  irritable  tissue  like  muscle  or 
nerve;  during  the  flow  of  the  current  the  irritability  of  the  tissue  is  modified  in 
the  neighborhood  of  the  two  electrodes,  being  heightened  at  the  cathode  and 
lowered  at  the  anode;  and  in  this  latter  region  the  nerve  may  become  com- 
pletely insensitive  to  stimuli  that  ordinarily  cause  strong  excitation.  The  inex- 
citable  state  thus  produced  is  called  "  anelectrotonus " ;  it  is  in  reality  a  form 
of  local  anesthesia,  and  as  such  has  been  employed  for  the  alleviation  of  pain 
in  sciatica  and  similar  conditions.  Muscle  is  affected  in  a  similar  manner;  the 
frog's  heart  may  thus  be  rendered  locally  incapable  of  contraction,  as  in  the 
simple  class  experiment  familiar  to  all  physiologists.  This  action  of  the  cur- 
rent probably   depends   on  its  altering  the  electrical  polarization   normal  to  the 


52  ANESTHESIA 

"Irritability  may,  however,  be  more  readily  modified  by  the  use  of 
chemical  substances  than  by  any  other  means,  and,  as  is  well  known, 
many  such  substances  are  in  daily  use  in  medical  and  surgical  practice 
for  procuring  local  or  general  insensibility  to  pain — hence  the  applica- 
tion of  the  name  'anesthetic'  to  the  large  class  of  substances  possessing 
this  property." 

Before  considering  the  mechanism  of  stimulation  and  of  its  modifi- 
cation by  anesthetics,  Lillie  reviewed  the  most  recent  conceptions  of  the 
nature  of  the  physico-chemical  constitution  of  the  living  cell.  He  re- 
gards it  as  clear  that  the  living  protoplasm  is  a  "polyphasic  system," 
that  is,  a  mixture  consisting  of  various  substances  and  solutions  which 
are  only  partly  miscible  with  one  another,  and  are  thus  interrelated  like 
the  different  phases  of  an  emulsion  or  similar  system.  "These  several 
phases,  which  are  partly  solid,  partly  liquid,  appear  in  each  living  cell 
to  have  a  constant  and  definite  arrangement,  whose  exact  nature  varies 
characteristically  from  cell  to  cell.  There  appears  typically  to  be  a  solid 
or  semi-solid  structural  substratum  consisting  of  colloidal  material,  most 
of  which  is  in  a  water-swollen  or  hydrated  state;  in  addition  to  this 
more  fixed  and  permanent  part  of  the  cell  organization,  numerous  sim- 
pler substances  are  present — sugars,  salts,  amino-acids  and  others — 
largely  in  a  state  of  simple  aqueous  solution,  but  probably  partly  ab- 
sorbed at  the  surfaces  of  the  colloidal  phases.  There  is  evidence  that  it 
is  by  the  oxidation  of  certain  of  these  substances,  especially  sugar,  rather 
than  of  the  colloidal  material,  that  most  of  the  energy  manifested  in  the 
cell-processes  is  set  free.  The  colloidal  substratum  furnishes  the  condi- 
tions under  which  the  energy-yielding  oxidations  and  other  metabolic 
changes  take  place,  and  apparently  determines  their  course,  character, 
and  velocity.  The  solid  colloidal  material  of  the  cell  may  in  one  sense  be 
considered  as  a  by-product  of  the  metabolic  activities  of  the  protoplasm ; 
it  appears,  once  formed,  to  undergo  itself  relatively  slight  change,  but  to 
influence  profoundly,  by  its  presence  and  arrangement,  the  character  of 
cell- metabolism.  The  colloids  are  of  varied  chemical  nature;  they  are 
chiefly  proteins  and  lipoids,  and  it  is  to  be  noted  that  they  are  built  up 
by  various  forms  of  molecular  union  and  polymerization  from  relatively 
simple  substances  furnished  by  the  environment.  This  is  true  not  only 
of  plants,  but  also  of  the  individual  cells  of  higher  animals,  where  the 
material  which  goes  to  form  proteins  reaches  the  cell  in  the  form  of 
amino-acids,  or  of  simple  polypeptides." 

membranes  of  the  irritable  elements — only  in  a  direction  the  inverse  of  that 
causing  stimulation.  There  is  much  evidence  that  the  state  of  polarization  of 
the  semipermeable  membranes  bounding  the  irritable  elements  is  an  important 
factor  in  determining  the  degree  of  responsiveness  to  stimulation;  the  facts  of 
electrotonus  indicate  that  by  altering  the  polarization  by  an  external  current 
the  irritability  of  the  tissue  may  be  changed  in  the  direction  either  of  increase 
or  of  decrease." 


GENERAL  PHYSIOLOGY  OF  INHALATION  ANESTHESIA      53 

"However  simply  organized  a  cell  may  seem,  there  are  certain  ele- 
ments of  structure  which  appear  always  to  be  present,  and  to  play  a 
fundamentally  important  role  in  stimulation  and  in  other  life-processes. 
These  are  the  membranes.  Most,  if  not  all,  living  cells  are  delimited 
from  the  medium  in  which  they  live  by  thin,  semi-permeable  colloidal 
surface-films,  the  so-called  plasma-membranes.  Similar  semi-permealjle 
partitions  are  often  found  in  the  cell-interior,  e.  g.,  about  nuclei, 
vacuoles,  chromatophores,  and  other  structures.  They  appear  to  be 
•formed  of  the  same  colloids  as  the  other  protoplasmic  structures,  namely, 
proteins  and  lipoids.  These  colloids,  like  many  other  organic  substancesj" 
have,  when  dissolved  in  water,  a  marked  influence  in  lowering  the  sur- 
face-tension of  the  solvent.  Any  substance  thus  acting  tends,  by  the 
operation  of  Gibbs'  principle,  to  collect  or  condense  on  the  free  surfaces ; 
if  the  substance  is  colloidal  in  nature  it  may  there  pass  out  of  solution 
and  form  a  solid  surface-film  or  membrane;  and  it  is  probably  under 
conditions  essentially  like  these  that  the  cell-membranes  are  formed. 
Artificial  membranes  similar  in  many  of  their  properties  to  the  plasma 
or  nuclear  membranes  of  cells  may  be  formed  in  protein  solutions  about 
droplets  of  chloroform,  mercury  or  other  water-immiscible  substances. 
Now  the  plasma-membranes  of  irritable  cells  undoubtedly  play  a  funda- 
mentally important  part  in  stimulation,  as  will  be  seen  below,  so  that  it 
will  be  necessary  to  consider  first  some  of  the  essential  properties  of  these 
membranes  before  passing  to  the  consideration  of  the  stimulation-process 
itself  and  its  modification  by  anesthetics. 

"The  plasma-membranes  are  typically  semi-permeable  structures — so 
much  so  that  living  cells  form  in  many  cases  the  most  convenient  and 
rapidly  acting  osmometers  that  we  possess.  Two  provisos  are  necessary 
in  making  use  of  living  cells  as  osmometers:  first,  the  dissolved  sub- 
stance must  not  by  its  own  action  impair  the  semi-permeability  of  the 
membrane,  and,  second,  it  must  not  appreciably  penetrate  the  membrane 
during  the  time  occupied  by  the  experiment.  The  plasma-membranes 
are,  in  fact,  semi-permeable  only  in  relation  to  certain  classes  of  sub- 
stances; toward  others  they  show  themselves  freely  permeable,  and  the 
character  of  these  substances  is  important,  because  indication  is  thus 
afforded  of  the  chemical  nature  of  the  materials  composing  the  mem- 
branes.-'^ This,  in  Lillie's  opinion,  is  a  matter  of  fundamental  impor- 
tance in  the  theory  of  anesthesia. 

"The  plasma-membrane  is  characteristically  and  intimately  con- 
cerned in  the  stimulation  process.  During  stimulation  it  appears  to 
undergo  a  sudden  and  quickly  reversible  increase  of  permeability.  The 
electrical  variation  is  one  expression  of  this  change,  but  there  are  others 
as  well.  Thus  the  movements  of  sensitive  plants,  which  occur  under  the 
same  conditions  of  stimulation  as  those  of  irritable  animal  tissues,  are 
due  to  a  collapse  of  turgid  cells,  consequent  upon  a  sudden  loss  of  the 


54  ANESTHESIA 

semi-peraieable  properties  of  the  plasma-membranes  enclosing  the  osmot- 
ically  active  solution  or  cell-sap.  Here  at  least  is  one  irritable  tissue 
where  the  connection  between  permeability  increase  and  stimulation 
seems  unmistakable." 

With  regard  to  why  anesthetics  interfere  with  the  stimulation- 
process,  Lillie  pointed  out  that  in  the  first  place  they  can  be  shown 
experimentally  to  interfere  with  both  of  the  characteristic  manifestations 
of  stimulation,  (1)  the  action-current  and  (2)  the  change  of  permeabil- 
ity. If  these  are  the  critical  or  primary  events  on  which  the  other 
effects  following  stimulation  depend,  it  is  evident  that  suppression  of 
these  must  involve  a  suppression  of  the  entire  series  of  processes  result- 
ing from  stimulation,  including  the  oxidations,  the  contraction-changes 
and  the  other  special  features  of  the  response. 

That  the  action-current  as  well  as  the  mechanical  response  of  a 
muscle  is  suppressed  by  anesthetization  has  long  been  knoivn.  In  nerves 
also,  anesthesia  abolishes  the  action-current.  On  the  foregoing  hypothe- 
sis, the  electrical  variation  is  the  expression  of  some  alteration  in  the 
plasma-membrane,  involving  a  temporary  increase  of  permeability. 
Hober  ^  has  found  that  potassium  salts,  which  deprive  nerves  of  irritabil- 
ity and  render  them  locally  negative,  cause  at  the  same  time  a  visible 
alteration  in  the  axis-cylinders;  these  structures  swell  and  stain  more 
diffusely;  he  found  further  that  these  effects  are  checked  or  prevented 
if  the  nerves  are  first  anesthetized  with  ethyl  urethan.  Experiments  on 
voluntary  muscle  gave  analogous  results.  If  a  frog's  muscle  is  partly 
dipped  into  an  isotonic  solution  of  a  potassium  or  rubidium  salt  the 
tissue  contracts  somewhat  and  becomes  locally  negative;  this  effect  is 
also  inhibited  or  retarded  in  the  presence  of  an  anesthetic.  If  the  local 
negativity  is  the  expression  of  a  change  produced  by  the  salt  in  the  col- 
loids of  the  plasma-membrane,  rendering  the  latter  more  permeable  than 
before,  Hober's  results  indicate  that  the  anesthetic  decreases  the  sus- 
ceptibility to  such  changes  of  permeability.  If  this  is  the  case  we 
can  partly  understand  why  the  anesthetized  tissue  becomes  less  sus- 
ceptible to  stimulation,  since  stimulation  involves  an  increase  of  per- 
meability. 

Lillie  concluded  that,  if  an  anesthetic  acts  by  so  modifying  the 
plasma-membrane  of  the  irritable  cell  as  to  render  difficult  or  impossible 
the  rapid  variations  of  permeability  which  are  essential  to  stimulation," 
"it  ought  to  act  similarly  on  other  cells,  i.  e.,  it  should  protect  these  cells 
also  against  the  action  of  permeability-increasing  substances  or  agencies. 
If  an  organism  can  be  found  whose  cells  undergo  immediate  and  obvious 
increase  of  permeability  under  conditions  which  at  the  same  time  cause 
stimulation,  it  should  become  possible  to  determine  whether  suppressing 
the  stimulating  action  of  a  given  agency  is  equivalent  to  a  suppression 

^  See  page  46. 


GENERAL  PHYSIOLOGY  OF  INHALATION  ANESTHESIA      55 

of  its  permeability-increasing  action.     The  two  effects  ought  to  sliow  a 
definite  parallelism  if  the  above  hypothesis  is  well  based." 

Lillie  investigated  the  antagonism  between  salts  and  anesthetics/ 
and  his  results  may  be  summarized  as  follows : 

1.  In  the  action  of  pure  isotonic  sodium  chlorid  solutions  on  Areni- 
cola  larvae  the  most  evident  effects  are:  (1)  strong  stimulation  of  the 
musculature,  causing  intense  and  prolonged  contraction;  (2)  increase 
in  the  permeability  of  the  pigment-cell  membranes  sufficient  to  allow 
visible  exit  of  pigment;  (3)  immediate  arrest  of  ciliary  movement,  fol- 
lowed by  disintegration  of  the  cilia;    and  (4)  a  general  toxic  action. 

2.  In  the  presence  of  a  large  number  of  anesthetics,  in  concentra- 
tions corresponding  to  those  producing  typical  neuromuscular  anes- 
thesia in  sea  water,  all  of  these  characteristic  immediate  effects  of  the 
pure  salt  solution  are  diminished  or  prevented. 

3.  In  general,  the  permeability-increasing  action  and  the  stimulat- 
ing action  of  the  salt  solution  undergo  closely  parallel  decrease  or  pre- 
vention in  the  presence  of  the  anesthetic.  Prevention  of  sudden  per- 
meability increase  thus  seems  equivalent  to  prevention  of  stimulation; 
it  is  also  equivalent  to  prevention  of  the  immediate  toxic  action  of  the 
solution.  The  anti-stimulating  and  the  anti-cytolytic  effects  of  the  anes- 
thetic thus  show  a  definite  parallelism. 

4.  In  anesthesia  the  essential  effect  is  a  temporary  alteration  in  the 
condition  of  the  swface  films  or  plasma  membranes  of  the  irritable  ele- 
ments, of  such  a  hind  that  these  membranes  no  longer  undergo,  under 
the  usual  conditions  of  stimulation,  the  rapid  increase  of  permeability 
essential  to  this  process. 

5.  The  membranes  thus  become  during  anesthesia  increasingly  re- 
sistant to  permeability-increasing  agencies:  this  involves  increased  resis- 
tance to  those  forms  of  toxic  action  which  depend  on  destruction  of  the 
normal  semi-permeability  of  the  membranes.  Hence  the  association  of 
an  anti-cytolytic  or  antitoxic  action  with  the  anti-stimulating  action  of 
the  anesthetic.  The  observations  made  by  Lillie  also  indicate  that  the 
degree  of  resistance  of  the  membranes,  and  of  other  colloidal  structures 
like  cilia,  is  intimately  dependent  on  the  state  of,  their  component 
lipoids.  /,/    . 

Conclusions. — It  appears  to  be  established  beyond  doubt  that  the 
anesthetic  is  in  solution  in  the  blood  during  narcosis,^  and  the  thorough 

"^Am.  J.  Physiol,  1913,  31,  No.  5,  255.  See  also  Science,  n.  s.  57,  Nos.  959, 
764.  ,  : 

-The  investigations  of  Tissot  (Compt.  rend.,  142,  234)  show  that  in  animal , 
rapidly  anesthetized  by  chloroform  the  amount  present  in  the  blood  may  exceed 
50  mg.,  more  than  70  mg.  per  iOO  c.c,  and  may  even  reach  70  to  80  mg.  If, 
however,  the  anesthesia  is  slowly  induced,  it  sinks  to  45  or  even  35  mg.  More 
than  70  mg.  per  100  c.c.  ,of  ;arterial  blood  often  causes  death.  Tissot  found 
that   the   amount   in   venous   blood    is    always   less   than   in   arterial   blood.      His 


56  ANESTHESIA 

investigations  of  Moore  and  Eoaf  strongly  point  to  the  fact  that  an 
unstable  compound  is  formed  with  hemoglobin,  just  as  occurs  in  the  case 
of  proteid.  It  is  probable  that,  in  every  case,  anesthesia  occurs  when  the 
unstable  compound  parts  with  the  anesthetic  to  the  cell  proteids,  and 
that  penetration  of  the  cells  by  virtue  of  the  anesthetic  to  the  cell  lipoid 
occurs  simultaneously.  In  this  way,  the  relative  power  of  the  various 
anesthetics  may  be  explained,  for  narcotic  action  is  here  dependent  upon 
solubility  in  blood,  stability  of  the  compound,  if  any,  formed  with  hemo- 
globin, rapidity  of  penetration  of  the  cells,  and  nature  of  the  solution 
in  the  cell  lipoids. 

EFFECTS  OF  INHALATION  ANESTHETICS  UPON  VARIOUS  PARTS 
OF   THE    ORGANISM 

When  a  volatile  agent  such  as  chloroform,  ether,  ethyl  chlorid  or 
nitrous  oxid  is  inhaled,  the  first  action,  naturally,  is  upon  the  respira- 
tory system.  Passing  from  the  air  vesicles  of  the  lungs  into  the  pul- 
monary blood  stream,  the  general  anesthetic  now  acts  upon  the  nervous 
mechanism,  and,  through  this,  upon  the  muscular  and  glandular  struc- 
tures, the  entire  organism  thus  becoming  more  or  less  profoundly  influ- 
enced. It  is  readily  conceivable  that  the  effects  upon  these  interdepen- 
dent vital  functions  cannot  be  considered  as  isolated  phenomena,  but 
must  be  dealt  with  as  correlated  features  of  the  complete  mechanism  of 
anesthesia. 

It  is  easily  understood  that  it  is  impossible  to  trace  the  effects  of  the 
agent  in  successive  steps  and  in  a  manner  that  is  applicable  to  all  cases. 
The  phenomena  may  vary  more  or  less  with  the  agent  employed,  with 
the  subject  anesthetized,  with  the  method  of  administration,  and  with 
various  conditions.  For  these  reasons,  the  discussion  of  the  physiological 
action  of  general  anesthesia  upon  the  human  subject  must  of  necessity 
be  general.  The  more  specific  action  of  the  individual  agents  is  given 
further  consideration  under  the  respective  subjects.  It  is  to  be  under- 
stood, furthermore,  that  the  phenomena  observed  are  those  of  a  clinical 
character,  rather  than  those  noted  by  the  experimental  physiologist. 

Effects  upon  the  Respiratory  System. — The  effect  of  anesthetic 
agents  upon  the  respiratory  system  may  be  considered  under  two  heads: 

(1)  The  primary  or  local  action  of  the  agent  upon  the  upper  respira- 
tory passages. 

(2)  The  secondary  or  general  action  upon  the  respiratory  system, 
resulting  from  the  stimulation  of  the  respiratory  center,  and  from  the 
effect  upon  the  muscular  system,  produced  by  the  circulating  anesthetic. 

Local  Effect. — The  direct  action  of  the  inhaled  anesthetic  upon  the 

work  seems  to  explain  satisfactorily  the  cause  of  chloroform  poisoning,  espe- 
cially when  considered  in  conjunction  with  the  work  of  Moore  and  Eoaf. 


GENERAL  PHYSIOLOGY  OF  INHALATION  ANESTHESIA      57 

respiratory  passages  may  cause  coughing,  a  sense  of  suffocation,  and 
temporary  suspension  of  respiration  ("holding  the  breath"). 

General  Effect. — This  varies  with  the  agent  employed,  the  method 
used,  the  subject  anesthetized,  and  other  factors;  it  also  varies  with  the 
stage  of  anesthesia. 

Ordinarily,  particularly  where  the  local  effects  are  inconsequent,  nor- 
mal respiration  becomes  deeper  as  the  respiratory  center  is  more  and 
more  profoundly  influenced  by  the  circulating  anesthetic,  and  more 
rapid  if  an  asphyxial  element  enters.  During  the  earlier  stages  of 
anesthesia  breathing  may  be  interfered  with  by  psychic  impulses.  This 
is  particularly  apt  to  be  the  case  with  nervous,  excitable  subjects,  and 
those  who,  through  fear,  resist  the  action  of  the  anesthetic.  With 
nitrous  oxid  or  other  agents  so  administered  as  to  cause  a  pronounced 
exclusion  of  oxygen  from  the  respiratory  apparatus,  there  is  apt  to  be 
exaggerated  or  stertorous  breathing,  and  the  muscles  of  respiration  are 
prone  to  assume  a  condition  of  tonic  or  clonic  spasm.  ( See  Effects  upon 
the  Muscular  System.)  There  may  be  temporary  suspension  of  respira- 
tion (apnea),  due,  according  to  recent  researches,^  to  a  fall  of  carbon 
dioxid  pressure  in  the  respiratory  center,  while  the  oxygen  pressure  is 
still  sufficiently  high  not  to  give  rise  to  excitement  of  the  respiratory 
center.  This  condition,  sometimes  called  "physiological  apnea,"  may 
merge  into  true  asphyxia  in  the  event  of  "pushing"  the  anesthetic  or  of 
allowing  undue  physical  constriction  in  any  part  of  the  respiratory  tract. 

It  is  to  be  borne  in  mind  by  the  anesthetist  that  the  rate,  rhythm, 
and  amplitude  of  respiration  are  subject  to  various  modifications  by 
traumatic,  thermal,  and  electrical  stimuli. 

The  interpretation  by  the  administrator  of  the  various  respiratory 
sounds  is  discussed  under  administration. 

Effects  upon  the  Circulatory  System. — The  effects  of  the  anesthetic 
agent  upon  the  Mood  itself,  upon  the  heart,  and  upon  Mood  pressure 
vary  with  the  drug  employed.  The  circulatory  changes  which  are  more 
or  less  characteristic  in  the  different  anesthetics  will  be  considered  more 
in  detail  under  the  special  physiology  of  each  agent. 

Experimental  physiologists  are  not  agreed  concerning  the  various 
factors  which  influence  the  circulatory  mechanism  during  inhalation 
anesthesia,  nor  are  they  agreed  with  reference  to  the  effects  of  the  anes- 
thetic agent  upon  the  blood  itself.  Certain  data  are  sufficiently  well 
established,  however,  to  be  of  practical  value,  and  to  these  attention  will 
be  confined. 

The  only  changes  produced  in  the  chemical  composition  of  the  blood 
by  the  circulating  anesthetic,  according  to  many  physiologists,  are  those 
arising  from  a  diminished  supply  of  oxygen.  It  has  been  claimed,  how- 
ever, by  other  investigators,  that  the  hemoglobin  content  of  the  red 

^J.  Fhysiol,  32,  225. 


58  ANESTHESIA 

corpuscles  is  markedly  decreased;  that  there  is  destruction  of  the  red 
corpuscles  (DaCosta),  and  that  the  urobilinuria  which  may  occur  two  or 
three  days  after  anesthesia  is  probably  the  result  of  this  destruction.  It 
is  also  claimed  that  lecithin  and  cholesterin  are  increased,  fat,  according 
to  Eeicher,  being  increased  up  to  two  or  three  times  the  normal  amount. 
Disintegration  of  the  fat  and  albuminoid  bodies  is  sufficient  to  lead  to 
the  increased  secretion  of  acetone.  The  specific  gravity  of  the  blood 
commences  to  rise  shortly  after  the  beginning  of  the  operation,  the  in- 
crease continuing  for  several  days  thereafter,  according  to  observations 
made  by  Sherrington  and  Copeman  ^  on  healthy  animals. 

Poggiolini  ^  investigated  the  morphological  changes  of  the  blood,  in 
ether  and  chloroform  narcosis,  in  a  series  of  experiments  on  healthy 
rabbits.  The  different  results  which  have  so  far  been  obtained  in  the 
examination  of  the  influence  of  ether  or  chloroform  narcosis  upon  the 
blood  are  referred  by  him  to  the  fact  that  the  influence  of  existing  dis- 
eases, of  the  operation  itself,  and  of  the  binding  of  the  animal  have  not 
been  sufficiently  considered.  His  experimental  findings  led  him  to  the 
following  conclusions : 

The  changes  of  the  blood  constituents,  noted  after  ether  or  chloro- 
form narcosis,  are  independent  of  the  duration  of  the  narcosis,  of  the 
quantity  of  the  narcotic,  of  the  frequency  of  the  narcosis,  and  of  the 
time-interval  between  the  individual  narcoses.  Deep  narcosis,  with  ether 
or  chloroform,  induces  leukocytosis,  of  variable  duration  and  degree.  At 
the  same  time,  the  relative  composition  of  the  leukocytes  is  changed, 
either  the  lymphocytes  or  the  neutrophile  polynuclear  cells  undergoing 
an  increase.  The  change  of  the  leukocyte  picture  persists  for  a  longer 
time  in  chloroform  narcosis  than  after  ether  narcosis.  The  red  blood 
corpuscles  and  the  hemoglobin  present  rather  variable  changes,  inde- 
pendent of  each  other,  after  the  two  narcoses.  However,  after  chloro- 
form narcosis  there  are  regular  destructive  and  retrogressive  changes  of 
the  red  blood  corpuscles,  which  are  absent  after  ether  narcosis.  Accord- 
ingly, inhaled  chloroform  appears  to  be  more  toxic,  and  of  a  more  pro- 
longed action,  than  ether,  in  the  opinion  of  Poggiolini. 

The  psychic  state  influences  the  circulation  in  the  initial  stage  of 
anesthesia,  as  manifested  by  pallor,  lividity,  syncope,  and  even  death. 
The  cardiac  and  vasomotor  centers  are  more  or  less  frequently  influenced 
in  such  cases,  these  exigencies  being  more  apt  to  occur  in  nervous  and 
excitable  patients,  particularly  those  who  are  frightened  before  begin- 
ning the  inhalation. 

Just  as  the  efficient  function  of  the  respiratory  system  during  anes- 

^  Sherrington  and  Copeman :  ' '  Variations  Experimentally  Produced  in  the 
Specific  Gravity  of  the  Blood,"  J.  Physiol.,  1893,  14,  52.   See  section  on  "Shock." 

2  Poggiolini :  "  Le  modificationi  morphologiche  del  sangue  nella  narcosi 
eterea  e  nella  cloro-narcosi, "  II  Policlinico,  1911,  Sez.  Chir.  18,  3-5. 


GENERAL  PHYSIOLOGY  OF  INHALATION  ANESTHESIA      59 

thesia  is  dependent,  in  part,  upon  the  circulatory  system,  so  is  the  proper 
condition  of  the  circulation  dependent  upon  respiration.  Obstruction  of 
the  respiratory  passages,  however  slight,  has  its  concomitant  circulatory 
disturbance.  A  slight  degree  of  obstruction  gives  rise  to  a  corresponding 
degree  of  venous  congestion,  manifested  by  freer  bleeding  at  the  site  of 
operation,  and  perhaps  by  the  swelling  of  the  tongue  and  adjacent  parts, 
these  changes  being  greater  in  some  subjects  than  in  others. 

The  action  of  the  anesthetic  upon  the  heart  may  be  primary,  but,  as 
a  rule,  it  is  secondary.  The  muscles  of  the  heart,  as  well  as  those  of  the 
arterioles,  are  directly  affected  by  the  anesthetic,  the  effect  varying 
according  to  the  particular  agent,  the  method  of  administration,  and  the 
extent  to  which  it  is  carried.  The  effect  may  be  that  of  direct  stimula- 
tion (as  with  ether)  or  of  direct  sedation  (as  with  chloroform). 

Changes  in  the  blood  pressure  are  dependent  upon  the  anesthetic 
employed  and  the  body  position.  With  nitrous  oxid  there  is  a  marked 
rise  in  blood  pressure;  with  ethyl  chlorid  there  is,  according  to  some 
observers,  a  slight  rise,  according  to  others  none;  with  ether  there  is 
first  a  rise  and  then,  with  deep  narcosis,  a  slight  fall;  with  chloroform 
there  is,  according  to  universal  agreement,  a  fall  in  blood  pressure.  The 
mechanism  of  the  rise  or  fall  is  a  disputed  point.  Some  physiologists 
have  maintained  that  the  fall  is  the  result  of  direct  vascular  dilatation; 
others  hold  that  it  is  due  to  dilatation  of  nervous  origin.  Kecent  experi- 
ments tend  to  establish  the  correctness  of  the  former  view. 

Various  other  factors  influence  the  circulation  during  anesthesia, 
such  as  hemorrhage  resulting  from  the  operative  procedure,  the  position 
of  the  patient,  deep  breathing,  and  positive  pressure.  According  to 
Eppinger  and  Hofbauer,^  "the  pulse  in  patients  whose  diaphragm  was 
unusually  high  or  low  showed  that  the  circulation  in  the  legs  was  better 
when  the  diaphragm  was  high,  as  the  quadrate  foramen  was  thus  left 
open.  When  the  diaphragm  is  low,  this  foramen  is  more  squeezed 
together  and  the  flow  of  blood  up  from  the  lower  part  of  the  body  is  thus 
impeded.  At  the  same  time,  deep  breathing  pushes  the  diaphragm  low 
down  and  it  thus  presses  on  the  liver  and  liver  veins  and  thus  promotes 
the  circulation  in  the  region." 

Effects  upon  the  Muscular  System. — The  effects  of  inhalation  anes- 
thetics upon  the  muscular  system  may  be  considered  under  two  head- 
ings: 

(1)  Direct,  which  are  of  interest  to  the  experimental  physiologist 
rather  than  to  the  practical  anesthetist,  inasmuch  as  they  involve  the 
direct  contact  of  the  muscle  with  the  anesthetic  agent,  a  contingency 
which  does  not  normally  arise  in  clinical  work. 

(2)  Indirect,  which  are  of  nervous  origin. 

The  indirect  muscular  phenomena  of  general  anesthesia  are  almost 
^ ' '  Kreislauf  und  Zwerchfell, ' '  Zeitsch.  f.  Min.  Med.,  72,  No.  1. 


60  ANESTHESIA 

entirely  controllable  by  certain  methods  of  administration,  to  which 
reference  will  be  made  in  detail  later.  Under  these  circumstances, 
namely,  the  administration  of  oil  of  bitter  orange  peel  as  a  preliminary 
to  the  anesthetic  agent,  the  conscious  voluntary  movements  of  the  pre- 
liminary stages  of  narcosis  are  practically  held  in  abeyance.  The  un- 
controllable muscular  movements  in  the  stage  of  excitement  are  absent 
because  there  is  no  such  stage.  Subconscious  purposive  movements  and 
simple  tonic  spasm,  local  or  general,  are  not  noted.  The  coordinated 
movements  sometimes  noted  in  deep  anesthesia  as  ordinarily  induced  are 
absent,  as  are  likewise  the  tremors  of  moderate  narcosis. 

The  usual  conscious,  subconscious,  and  unconscious  movements,  the 
tremors  and  clonic  spasms  noted  during  the  administration  of  any  of  the 
inhalation  anesthetic  agents,  or  the  ordinary  combination  of  these,  are 
more  or  less  completely  held  in  abeyance  by  the  action  of  oil  of  orange, 
administered  as  a  preliminary  to  these  agents.  (See  Preceding  the  Ad- 
ministration with  Oil  of  Bitter-Orange  Peel,  p.  91.)  For  further  details 
concerning  effects  upon  muscular  system,  see  Special  Physiology  of  each 
agent. 

Effects  upon  the  Glandular  System. — The  effects  of  general  anes- 
thetics upon  the  glandular  system  may  be  considered  under  two  heads: 

(1)  The  immediate  effects,  or  those  noted  during  the  administra- 
tion, 

(2)  The  secondary,  or  after-effects,  or  those  observed  after  the  sub- 
sidence of  anesthesia,  when  the  anesthetic  agent  is  no  longer  circulating 
in  the  blood. 

Both  the  immediate  and  the  after-effects  vary  with  the  anesthetic 
agent,  with  the  method  of  administration,  with  the  degree  to  which  nar- 
cosis is  carried,  and  with  various  other  factors  to  be  discussed  more  in 
detail  under  the  special  physiology  of  each  anesthetic. 

The  immediate  effects  involve  particularly  the  mucous,  salivary, 
sweat,  and  lachrymal  glands.  The  secretion  of  mucus  and  saliva  is 
greater  during  light  and  moderate  narcosis,  whereas  it  is  decreased  dur- 
ing the  deeper  stages.  The  same  holds  true  with  lachrymation  with  all 
the  general  anesthetic  agents.  The  sweat  glands  are  more  or  less  affected 
in  the  various  stages  of  narcosis  by  the  different  anesthetics.  In  the 
presence  of  cyanosis  or  severe  shock  with  any  agent,  the  sweat  glands 
become  hyperactive,  as  evidenced  by  the  ''cold  perspiration"  which  sub- 
sides with  the  restoration  of  proper  respiration  and  circulation. 

Eenal  function  is  interfered  with  during  the  administration,  accord- 
ing to  some  observers,  being  increased  up  to  the  point  at  which  the 
corneal  reflex  disappears  and  completely  arrested  during  profound  anes- 
thesia. This  decreased  secretion  of  urine  during  the  administration  may 
continue  to  the  point  of  complete  suppression,  resulting  in  death.  Vari- 
ous  intermediate  degrees   of  suppression  and  concentration,  with   in- 


GENERAL  PHYSIOLOGY  OF  INHALATION  ANESTHESIA      61 

creased  chlorids,  phosphates,  urea,  casts,  and  albumin  in  greater  or  less 
quantity,  have  been  noted,  the  urine  gradually  returning  to  normal 
within  a  week  after  the  anesthesia. 

These  observations  apply  to  chloroform  and  ether.  Tlie  occurrence 
of  albuminuria  during  the  administration  of  inhalation  anesthetics  is 
said  to  occur  with  some  of  the  agents  and  not  with  others. 

Fatty  degeneration  of  the  liver,  kidneys,  heart,  and  other  organs  may 
occur,  particularly  after  repeated  administrations  of  chloroform,  unless 
safeguarded  by  heat,  moisture,  oxygen,  and  rebreathing,  together  with 
enemas  of  normal  saline,  olive  oil,  and  glucose.^ 

Effects  upon  the  Nervous  System. — The  sequence  in  which  the  parts 
of  the  nervous  system  are  involved  in  the  production  of  general  anesthe- 
sia is  still  the  subject  of  discussion  among  experimental  physiologists  as 
well  as  practical  anesthetists.  English  and  American  investigators  hold 
that  the  cerebral  cortex  is  first  involved;  the  basic  ganglia  and  cere- 
bellum,^ second;  the  sensory  centers  of  the  cord  which  connect  the  brain 
with  the  periphery,  third;  the  cerebro-spinal  motor  tracts  and  centers, 
fourth;  and  the  respiratory,  vasomotor,  and  cardiac  centers  of  the 
medulla,  fifth.  Inhibition  of  all  functions,  and  death,  folloAv.  Accord- 
ing to  Dastre  and  other  French  observers,  the  sensory  nuclei  of  the  cord 
or  the  cerebral  ganglia  are  affected  before  the  cortical  centers  are 
involved. 

The  order  in  which  the  special  senses  are  affected  by  the  general  anes- 
thetic cannot  be  definitely  stated.  The  majority  of  observers  seem  to  be 
agreed  that  sight  is  lost  before  hearing,  and  that  taste  persists  longer 
than  either  of  these.  With  nitrous  oxid,  hearing  is  the  last  sense  to 
disappear  and  the  first  to  reappear.  The  sense  of  smell  is  very  easily 
lost,  as  is  witnessed  in  the  effect  of  oil  of  bitter  orange  peel,  to  which 
reference  has  been  made. 

The  refiex  phenomena  of  general  anesthesia  may  occur  during  any 
stage  of  narcosis,  from  the  beginning  of  the  induction  period  to  the 
period  immediately  preceding  inhibition  of  respiration.  They  vary  con- 
siderably with  different  patients. 

The  refiex  circulatory  phenomena  are  of  special  importance  from  a 
practical  point  of  view.  They  may  arise  during  all  stages  of  anesthesia, 
and  they  may  vary  in  intensity  from  slight  reflex  vasomotor  stimulation 

^  See  Chapter  on  Treatment,  Preliminary,  During,  and  After  Anesthesia. 

^Francis  and  Fortescue-Brickdale  ("The  Chemical  Basis  of  Pharmacology," 
1908,  81)  state  that  the  physiological  action  of  the  entire  group  of  aliphatic  nar- 
cotics is  first  on  the  higher  centers  of  the  cerebrum,  then  on  the  lower  centers 
of  the  medulla  and  cord.  Eventually,  continue  these  authors,  the  reflexes  are 
completely  abolished,  and  this  constitutes  an  important  distinction  between  this 
group  and  the  alkaloidal  narcotics,  of  which  the  principal  representative  is  mor- 
phin.  In  large  doses  morphin  increases  reflex  irritability,  and  in  smaU  doses 
does  not  depress  it. 


62  ANESTHESIA 

or  inhibition,  with  consequent  rise  or  fall  of  blood  pressure  during  the 
earlier  stages,  to  profound  circulatory  shock  during  the  stage  of  deep 
narcosis.  They  vary  with  the  anesthetic  employed,  being  more  com- 
monly manifested  with  chloroform  than  with  ether ;  with  the  method  of 
administration,  being  largely  eliminated  by  the  modern  methods  (see 
Chapter  VIII)  ;  with  the  degree  to  which  the  anesthesia  is  carried;  and 
with  the  state  of  the  nerve  centers  (vasomotor,  cardio-inhibitory,  cardio- 
accelerator)  acted  upon  by  the  anesthetic  agent. 

Eeflex  circulatory  disturbances  of  a  serious  nature,  occurring  during 
the  earlier  stages  of  anesthesia,  before  consciousness  is  entirely  lost,  are 
often  of  psychic  origin.  It  is  important,  for  this  reason,  that  the  sur- 
gical procedure  be  not  commenced  until  anesthesia  is  complete. 

The  occurrence  of  circulatory  shock  after  the  induction  of  general 
anesthesia  has  been  the  subject  of  much  serious  investigation,  the  work 
of  Crile  ^  being  particularly  noteworthy.^ 

Eeflex  respiratory  phenomena  are  more  frequently  present  during 
the  lighter  than  during  deeper  degrees  of  narcosis.  It  is  to  be  borne  in 
mind,  however,  that  the  psychic  stimuli  of  the  conscious  stages  of  anes- 
thesia may  give  place  to  the  traumatic  stimuli  of  the  stage  of  surgical 
anesthesia.  These  stimuli,  applied  in  any  part  of  the  body,  may  cause 
reflex  spasmodic  movement  of  the  tongue,  whereby  this  organ  is  drawn 
over  the  laryngeal  orifice,  giving  rise  to  laryngeal  spasm,  respiratory 
and  expiratory  spasm,  coughing,  retching,  and  stertorous  breathing. 

When  these  phenomena  assume  a  serious  and  menacing  character, 
the  condition  is  described  as  "respiratory  shock."  This  is  most  apt  to 
supervene  during  moderate  anesthesia. 

FACTORS  WHICH  MAY  BE  SAID  TO  MODIFY  THE  PHYSIOLOGY 
OF  ANESTHESIA  AS  ORDINARILY  INDUCED 

It  has  been  suggested  ^  that  the  phenomena  resulting  from  the  ad- 
ministration of  inhalation  anesthetic  agents  more  properly  come  under 
the  head  of  pathology  than  of  physiology.  However  this  may  be,  certain 
it  is,  as  elsewhere  stated,  that  practically  every  phenomenon  varies  with 
the  particular  anesthetic  agent  administered,  with  the  general  condition 
of  the  patient,  with  the  condition  of  the  blood,  and  with  various  other 
factors. 

For  these  reasons,  it  has  been  deemed  advisable  to  consider  here  cer- 
tain factors  which,  introduced  into  the  administration  of  inhalation 
anesthetics,  may  be  said  to  modify,  to  a  more  or  less  pronounced  degree, 

^  Grile,  G.  W. :  "  Surgical  Shock. ' '  Also,  Boston  Med,  and  Surg.  J.,  March, 
1903. 

''  Chapter  on  Treatment,  p.  41. 
3  Wright,  Hamilton :     Loc.  cit. 


GENERAL  PHYSIOLOGY  OF  INHALATION  ANKSTilKSlA      63 

some  of  the  phenomena  ordinarily  ohserved,  and  commonly  considered 
under  the  head  of  physiology.     These  factors  are : 

1,  Warming  the  agent;  2,  utilizing  moisture;  3,  combining  oxygen 
with  the  agent;  4,  preceding  the  administration  with  oil  of  bitter 
orange  peel;  5,  utilizing  carbon  dioxid;  6,  rebreathing.^ 

The  consideration  of  these  factors,  particularly  the  first,  necessarily 
involves  the  introduction  of  a  certain  amount  of  technique,  which,  of 
itself,  would  no  doubt  more  properly  come  within  the  chapter  on  Ad- 
ministration, or  perhaps  Special  Physiology.  The  following  discussion 
may  be  considered,  therefore,  as  an  addendum  to  General  Physiology. 

Warming  the  Agent. — The  value  of  warmed  anesthetics  has  been 
recognized  by  many  anesthetists  since  Clover  ^  devised  his  double- 
current  apparatus,  by  means  of  which  the  expired  air  warmed  the  anes- 
thetic agent.  Since  that  time  various  attempts  have  been  made  to 
deliver  to  the  patient  warmed  ether  or  other  agent,^  but  in  each  instance 
the  apparatus  was  found  to  be  inadequate,  too  complicated  for  practical 
use,  or  otherwise  unsatisfactory. 

It  was  not  until  1905,  however,  that  systematic  laboratory  experi- 
ments and  clinical  observations  were  begun,*  with  a  view  to  determining 
the  relative  value  of  the  various  inhalation  anesthetics  when  these  are 
administered  cold  and  when  they  are  warmed  to  the  temperature  of  the 
blood  (98.6°  P.).  These  observations  were  made  by  Gwathmey  par- 
ticularly with  reference  to:  (1)  safety  as  regards  life;  (2)  the  main- 
tenance of  body  temperature,  and  the  consequent  lessening  of  the  danger 
of  shock;  (3)  recovery  from  the  anesthetic;  and  (4)  after-effects. 
Other  phenomena  were  also  noted. 

Safety  to  Life. — First,  with  chloroform:  In  order  to  determine 
the  value  of  chloroform  as  regards  life  when  heated  to  100°  F.  and  at 
room  temperature,  Gwathmey  °  made  a  number  of  experiments,  using 
compressed  air  and  passing  this  air  through  chloroform  at  room  tem- 
perature and  then  to  a  special  animal  mask,  using  a  Junker  inhaler  for 
the  chloroform.  He  found  that  it  took  6.57  minutes  on  the  average  to 
kill  sixteen  animals.  Employing  the  same  technique  with  the  addition 
of  another  Junker  inhaler,  filled  with  warm  water  and  placed  in  a  warm 
receptacle  between  the  chloroform  and  animal  mask,  he  found  that  the 
average  time  required  to  kill  seventeen  animals  was  20.35  minutes,'^  thus 

^  Chapter  on  Eebreathing. 

=  Clover:     Brit.  Med.  J.,  March  15,  1873,  282;  July  15,  1876,  74;  Jan.  20,  1877. 

'(1)  Hawksley:  Brit.  Med.  J.,  Aug.  2,  1873,  177.  (2)  Foy:  "Anesthetics, 
Ancient  and  Modern,"  141. 

*  Gwathmey:  Med.  Bee,  Oct.  14,  1905;  N.  Y.  Med.  J.,  Feb.,  1908;  J.  Am. 
Med.  Assn.,  Oct.  27,  1906;  Am.  J.  Surg.,  July,  1908.  See  also  Coburn:  Med. 
Bee,  March  1,  1913. 

'^  For  technique,  see  p.  317. 

*See  table,  p.  64. 


64  ANESTHESIA 

showing  that  chloroform  at  blood  temperature  is  three  times  as  safe  as 

chloroform  at  room  temperature. 

TIME   EEQUIEED   TO   KILL   ANIMALS   WITH   CHLOROFOEM   AND    AIE 

No.  of  minutes  required  No.  of  minutes  required 

No.  of  experiment  to  kill  at  100°  F.  to  kill  at  normal 

^  temperature 

1 18  4.5 

2 57  3 

3 26.5  7.5 

4 24.5  7 

5 15  4 

6 16  4 

7 15  3.5 

8 8  7.5 

9 13  9 

10 22  5.5 

11 12  7 

12 17  10 

13 21  6 

14 25  9 

15 27  10 

16 17  7.5 

17 12  

17)346  16)105 

20.35  6.57 

Second,  with  nitrous  oxid  and  oxygen  instead  of  chloroform,  and 
passing  the  mixed  gases  through  a  tube,  first  at  room  temperature,  and 
then  surrounding  the  tube  with  hot  water,  and,  last,  surrounding  the 
tube  with  ice,  and  in  all  instances  measuring  the  temperature  accurately 
by  a  thermometer  placed  in  a  bent  tube,  using  the  same  animal  mask 
and  giving  all  animals  first  six  per  cent  of  oxygen  with  nitrous  oxid 
for  five  minutes,  and  then  reducing  the  amount  of  oxygen  to  three  per 
cent,  the  following  results  were  obtained:  Twelve  animals  were  anes- 
thetized and  killed  by  nitrous  oxid  and  oxygen  at  room  temperature. 
The  average  time  for  the  eye  and  extremity  reflexes  to  be  abolished  was 
4  minutes.  The  average  time  required  to  kill  was  9  minutes  and  20 
seconds.  The  shortest  time  was  4  minutes  and  the  longest  12  minutes. 
Nine  of  these  animals  struggled  violently  until  anesthetized;  two  were 
quickly  asphyxiated;  one  weakling  remained  quiet  after  two  minutes. 
In  all  cases,  heart  action,  rapid  at  the  start,  ran  from  150  up  to  200 
during  the  frightened  struggles;  as  anesthesia  progressed,  it  again 
became  irregular,  with  marked  second  sound  accentuation,  and  very 
rapid  and  weak  Just  before  death.  The  respiration  in  all  cases  was 
irregular,  and  gasping  to  variable  degrees.  In  all  cases  tonic  convul- 
sions occurred  just  before  death.  In  25  per  cent  of  the  cases  convulsions 
occurred  during  the  first  three  to  five  minutes    (probably  anoxemia ) ; 


GENERAL  PHYSIOLOGY  OF  INHALATION  ANESTHESIA      65 

continuation  of  heart  action  after  respiration  ceased:  average  time,  2 
minutes;   longest,  3  minutes;    shortest,  1  minute. 

Twelve  animals  were  anesthetized  with  warm  nitrous  ox  id  and  oxy- 
gen by  having  the  tube  containing  the  mixture  of  gases  passed  through  a 
hot  water  bath  kept  at  a  temperature  of  98°  C.  The  same  proportions 
were  used  as  in  the  administration  of  the  cold  gases.  In  all  other  re- 
spects the  technique  was  the  same  as  far  as  the  experimenter  could 
possibly  make  it. 

Abolition  of  Eeflexes. — Two  animals  (weaklings),  anesthetized 
with  6  per  cent  oxygen  mixture,  lost  their  reflexes  at  the  end  of  5 
minutes;  6  animals  had  reflexes  abolished  with  the  3  per  cent  oxygen 
mixture  in  13  to  25  minutes,  the  average  time  being  18  minutes.  Four 
were  not  anesthetized  at  the  end  of  30  minutes.  After  the  removal  of 
the  inhaler,  2  were  able  to  walk  in  from  one  to  two  minutes.  The  other 
2  were  killed.  Eight  animals  were  killed  by  the  anesthetic ;  the  average 
time  was  18  minutes.  Four  were  in  good  condition  at  the  end  of  30 
minutes;  two  were  disposed  of  as  noted  above;  and  two  were  put  away 
for  future  work.  The  shortest  time  was  12  minutes;  the  longest  time, 
28  minutes.  Eight  struggled  from  1  to  3  minutes  because  held,  and 
the  remainder  did  not  struggle  after  the  first  few  breaths. 

Heart  Action". — After  preliminary  excitement,  action  was  regular 
in  force  and  frequency  until  death  approached,  when  it  became  rapid 
and  weak. 

Eespieation. — In  all  cases  respiration  was  quiet  and  regular  after 
the  first  few  minutes,  becoming  gasping  just  before  death. 

Convulsions. — No  early  convulsions  occurred.  Mild  tonic  convul- 
sions occurred  just  before  death.  Continuation  of  heart  action  after 
cessation  of  respiration:  average,  3^  minutes;  shortest,  2  minutes; 
longest,  5  minutes. 

The  third  series  of  experiments  was  conducted  in  precisely  the  same 
manner  as  the  first  two,  as  regards  technique,  percentage  of  oxygen,  etc., 
with  this  difference:  the  tube  containing  the  mixture  of  gases  passed 
through  a  vessel  packed  in  ice.  The  U-shaped  tube  containing  the  ther- 
mometer was  also  packed  in  ice.  The  thermometer  did  not  vary  from 
33°  to  34°  F.  during  the  administration.  Ten  animals  were  killed.  The 
results  were  as  follows :  After  eight  to  ten  breaths  of  this  cold  mix- 
ture, violent  struggling  ensued  and  breathing  ceased  almost  immedi- 
ately. Fibrillary  twitchings  greatly  resembling  a  chill  occurred  in  all 
animals  after  the  first  minute  of  inhaling  the  mixture.  The  average 
time  required  to  kill  was  5  minutes  and  31  seconds,  or  about  4  minutes 
less  than  at  the  normal  temperature,  and  13  minutes  less  than  the  S 
animals  killed  by  the  warmed  gases.  The  shortest  time  was  3  minutes 
and  55  seconds;   the  longest  time,  7  minutes. 

From  the  above,  it  will  be  seen  that  warmed  nitrous  oxid  and  oxy= 


66  ANESTHESIA 

gen  is  much  safer  than  using  this  mixture  of  gases  at  the  room  tempera- 
ture, and  very  much  safer  than  the  cold  gases. 

The  following  case  history  illustrates  very  clearly  the  difference  be- 
tween cold  and  warm  nitrous  oxid  and  oxygen  as  observed  in  the  human 
subject.    A  large  number  of  similar  histories  could  be  cited. 

Female.  Age,  about  45  years.  April  19,  1907.  Patient  was  given 
1/4  grain  of  morphin  and  1/150  grain  of  atropin  thirty  minutes  before 
the  operation.  Operation  (laparotomy)  lasted  two  hours,  during  the 
whole  of  which  time  the  patient  was  kept  under  the  influence  of  nitrous 
oxid  and  oxygen,  without  the  aid  of  any  other  anesthetic.  A  fibroid 
tumor  weighing  thirty-five  pounds  was  removed.  At  the  end  of  one  hour 
the  anesthetist's  (J.  T.  G.)  gas  tanks  became  exhausted,  and  he  was 
compelled  to  use  the  hospital  tanks,  which  unfortunately  were  of  such 
size  and  condition  that  he  could  not  use  his  hot-water  attachments.  As 
soon  as  he  began  using  the  cold  gases,  the  respirations  showed  a  marked 
decrease  in  number  and  were  slightly  labored,  but,  with  this  exception, 
the  narcosis  was  entirely  satisfactory,  the  patient  making  an  uneventful 
recovery  and  without  nausea  or  vomiting. 

Third,  with  ether:  Only  a  few  experiments  were  conducted  with 
ether,  but  the  number  was  sufficient  to  fully  convince  one  that  warm 
ether  acts  similarly  to  warm  chloroform  and  warm  nitrous  oxid;  that 
is,  it  is  twice  as  safe,  as  shown  by  the  fact  that  it  took  over  twice  as 
long  to  kill  the  animals  with  warm  ether  vapor  as  with  cold. 

Fourth,  with  ethyl  chlorid:  We  have  made  no  experiments  with 
warm  ethyl  chlorid,  but  by  analogy  we  may  conclude  that,  as  chloro- 
form, ether,  and  nitrous  oxid  are  increased  in  value  by  heat,  the  value 
of  ethyl  chlorid  would  likewise  increase. 

From  the  animal  experiments  with  the  different  anesthetics,  i.  e., 
chloroform,  ether,  and  nitrous  oxid  and  oxygen,  first  at  the  room  tem- 
perature, and  then  heated  to  the  temperature  of  the  blood,  and  finally 
with  nitrous  oxid  and  oxygen  at  -|-  33°  to  -|-  34°  F.,  we  conclude  that  all 
anesthetics  heated  to  the  temperature  of  the  blood  are  increased  in  value 
as  regards  life,  without  decreasing  their  anesthetic  effect.  From  these 
experiments  it  is  also  evident  that  to  these  highly  sensitive  creatures 
the  warm  gases  were  much  pleasanter  to  inhale.  From  clinical  experi- 
ence it  can  be  stated  positively  that  the  facts  learned  in  the  laboratory 
are  beyond  all  question  true  also  in  practice. 

The  Maintenance  of  Body  Tempeeature. — A  large  number  of 
observations  have  been  made  with  reference  to  the  effect  of  narcosis  upon 
the  body  temperature.^     The  loss  of  body  temperature  observed  in  all 

^Kapeler:  " Ansesthetica, "  Deut.  Chir.,  1880,  33,  168;  Hare:  "Experi- 
ments to  Determine  tlie  Influence  of  Etherization  on  the  Normal  Bodily  Tem- 
perature, etc.,"  Therap.  Gaz.,  1888,  1^,  317;  Dastre:  ''Les  anesthetiques : 
physiologie    et    applications    chirurgicales, "    Paris,    1890;    Allen:      "Effect    of 


GENERAL  PHYSIOLOGY  OF  INHALATION  ANESTHESIA      67 

instances,  both  in  the  experiments  upon  animals  and  in  clinical  observa- 
tions upon  the  human  subject,  has  been  variously  explained  as  being  due 
to  diminution  of  oxidation,  to  radiation  of  heat  from  uncovered  portions 
of  the  body,  to  the  effect  of  the  anesthetic  agent  upon  the  regulatory 
centers,  to  the  increased  output  of  heat  in  consequence  of  dilatation  of 
the  cutaneous  vessels,  etc. 

Whatever  the  cause  of  this  loss  of  body  temperature,  it  is  interesting 
to  note  that  even  a  fraction  of  a  degree  of  elevation  of  temperature  of 
the  anesthetic  agent  above  that  of  the  room  will  have  a  marked  effect  in 
maintaining  the  body  temperature  of  the  patient.  The  author's  observa- 
tions in  this  regard  have  been  amply  verified  by  those  of  Davis,^  both 
upon  animals  and  upon  human  subjects. 

'In  twenty-six  patients  anesthetized  with  warm  ether  vapor,  there 
was  a  loss  of  body  temperature  averaging  .29°  F.  as  against  the  loss  of 
1.02°  F.  in  one  hundred  and  forty  cases  anesthetized  under  similar  con- 
ditions with  the  open  drop  method.  The  shortest  period  of  anesthesia 
in  which  the  temperature  was  noted  was  forty  minutes,  the  longest  four 
and  three-quarter  hours.  The  temperature  was  taken  by  rectum  imme- 
diately before  starting  and  immediately  after  the  removal  of  the  anes- 
thetic. 

These  experiments  of  Davis  upon  human  beings  undergoing  surgical 
operations  are  most  conclusive.  The  practical  application  of  this  lies 
in  the  fact  that  in  the  majority  of  instances  the  patient's  temperature  is 
necessarily  lowered  by  the  surgical  operation,  and  also  by  the  anesthetic 
as  usually  administered. 

In  this  connection  it  may  be  well  to  emphasize  the  fact,  mentioned 
by  Davis,^  that  an  undue  elevation  of  the  body  temperature,  as  a  conse- 
quence of  employing  a  warmed  anesthetic  agent  or  as  a  result  of  other 
measures,  may  prove  injurious.  In  one  of  his  animal  experiments  the 
body  temperature  of  the  subject  was  elevated  by  means  of  an  electro- 
thermal pad  and  blankets.  There  was  a  rise  of  4.14°  F.  in  one  and 
three-quarter  hours,  at  which  point  death  suddenly  occurred.  An  over- 
dose of  ether  was  a  presumptive  factor,  but  the  chief  factor  was  thought 
to  be  this  great  increase  in  temperature. 

The  following  are  the  charts  of  two  human  subjects,  in  which  death 
was  supposed  by  Davis  to  have  been  caused  by  giving  a  warmed  anes- 
thetic for  too  long  a  time.  In  the  second  case,  that  of  a  child  five 
months  old,  it  would  seem  that  the  shock  from  too  long  an  anesthetic 

Anesthesia  upon  the  Body  Temperature  and  Blood  Pressure,"  Trans.  Am.  Surg. 
Assn.,  1896,  14,  367;  Morley:  "The  Effect  of  Anesthesia  upon  the  Body  Tem- 
perature," Am.  Gynecology,  1903,  No.  3,  300. 

^  Davis:  "On  the  Effect  of  Narcosis  upon  the  Body  Temperature,"  Johns 
EopMns  Eosp.  Bull.,  April,  1909,  118. 

'^  Loc.  cit. 


68 


ANESTHESIA 


and  not  the  warmed  ether  vai3or  was  the  immediate  cause  of  death, 
following  are  the  records :  ^ 


The 


Name — H.  G. 

Address — Johns  Hopkins  Hospital, 

Age — 35. 

Surgeon — Gushing. 

Operation — Gerebellar  Exploration. 

Anesthetic — Ether  Vapor  Warmed. 

Amount — 225  gm. 

Temp,  before  anesth. — 38. 

Temp,  after  anesth. — 40.44. 

Temp,  operating  room — 31.1 


CASE  1 


Sex—M. 


Date— October  7,  1908. 


Method — Open. 
Duration — 3  hours. 


Narcotics — None. 
StimMants — None. 
Complications. 


Temperature  two  hours  after  the  anesthetic,  41.3°.     Patient  died  one  hour 


later. 


CASE  '2 


Da^e— May  29,  1908. 
Weight — 


Name — C.  C. 

Address — Johns  Hopkins  Hospital. 

Age—b  M.  Sex—M.. 

Surgeon — Gushing. 

Operation — Spina  Bifida. 

Anesthetic — Ether  Vapor  Warmed.  Method — Open. 

Amount — 50  gm.  Duration — 2i  hours. 

Temp,  before  anesth. — 38.  Narcotics — None. 

Temp,  after  anesth. — 39.8  Stimulants — None. 

Temperature  operation  room — 29.5. 

Complications 
Anesthesia  ended  5.00  p.  m.,  Temperature,  39.8. 
5.30  p.  m.,  Temperature,  40.5. 
6.00  p.  m.,  Temperature,  40.1. 
6.30  p.  m.,  Temperature,  40.2. 
7.00  p.  m..  Temperature,  40.5. 
7.30  p.  m..  Temperature,  40.8. 
8.00  p.  m..  Temperature,  41.4. 
Died,  8.25  p.  m. 

It  may  be  interesting  in  this  connection,  before  considering  the  ques- 
tion further,  to  note  some  observations  concerning  the  temperature  stim- 
ulus as  applied  to  certain  agents. 

^Private  communication  from  Dr.  Davis. 


GENERAL  PHYSIOLOGY  OF  INHALATION  ANESTHESIA      69 

Hoffmann/  in  his  discussion  of  the  cooling-off  of  the  inspired  air 
and  its  causative  connection  with  post-operative  pulmonary  affections, 
says  that,  in  the  ether-drop-anesthesia  according  to  Witzel,  there  occurs 
an  automatic  regulation  of  the  ether  contents  of  the  inspired  air.  This 
self-regulation  is  brought  about  through  a  considerable  refrigeration  of 
the  temperature  of  the  inspired  air.  This  cooling  can  be  avoided  with- 
out disturbance  of  the  automatic  regulation,  by  the  utilization  of  a 
suitable  mask. 

Stursberg  -  discussed  the  behavior  of  blood  pressure  under  the  action 
of  temperature-stimuli  in  ether  and  chloroform  anesthesia,  as  well  as  its 
bearing  upon  the  occurrence  of  subsequent  complications.  In  ether  nar- 
cosis it  will  be  found  that  a  cold  stimulus  is  followed  by  vascular  con- 
traction, possibly  without  a  later  reactive  dilatation,  thus  supplying  the 
conditions  for  "catching  cold." 

The  action  of  chloroform,  Stursberg  found,  is  not  generally  followed 
by  extensive  vascular  contraction  on  the  refrigeration  of  the  skin;  con- 
sequently, the  distribution  of  the  blood  is  not  altered  in  the  sense  of  an 
induced  hyperemia  of  the  internal  organs,  which  does  away  with  a  condi- 
tion favoring  the  origin  of  "colds." 

Eecovery  from  the  Anesthetic. — With  the  idea  of  testing  the 
influence  of  heat  upon  the  recovery  of  the  subject  from  the  anesthetic, 
Gwathmey  anesthetized  three  animals  at  the  same  time,  under  glass 
receptacles,  for  ten  minutes,  afterward  placing  them  in  receptacles,  one 
at  0°  F.,  another  at  100°  F.,  the  third  being  allowed,  as  a  control,  to 
come  out  in  the  room  temperature.  The  animals  were  changed  in  posi- 
tion on  three  successive  days.  In  each  instance,  the  animal  in  the  warm 
chamber  made  a  slightly  more  rapid  recovery  than  the  others.  The  ani- 
mal in  the  cold  box  came  out  in  chills,  while  the  one  in  the  room  tem- 
perature came  out  a  close  second  to  the  one  in  the  warm  box. 

With  reference  to  human  beings,  it  may  be  stated  that,  by  applying 
hot  towels  to  the  patient's  face,  or  by  aerating  the  lungs  with  hot  air 
toward  the  close  of  any  anesthesia,  the  patient  recovers  quickly  from  the 
anesthetic. 

It  will  thus  be  seen  that  recovery  from  the  anesthetic  is  facilitated 
by  the  natural  inhalation  of  warmed  atmospheric  air,  or  by  the  artificial 
introduction  into  the  lungs  of  a  current  of  warmed  air.  Experimental 
and  clinical  observations  have  abundantly  verified  these  findings  with 
reference  to  the  use  of  warmed  anesthetics. 

^  Hoffmann,  M. :  "  Ueber  die  Abkiihlung  der  Inspirationsluf t  bei  der 
Aethertropf narkose,  ihre  Bedeutung  und  ihre  Verhutung, ' '  Mittlg.  a.  d.  Grensgeb. 
d.  Med.  u.  CUr.,  1910,  31,  869. 

-  Stursberg,  H. :  "  Ueber  das  Verhalten  des  Blutdruckes  unter  des  Einwirkung 
von  Temperaturreizen  in  Aether  und  Chloroform  Narkose, ' '  Mittlg.  a.  d.  Grens- 
geb. d.  Med.  u.  CUr.,  1911,  ^f,  1. 


70  ANESTHESIA 

After-Effects. — A  great  deal  has  been  written,  by  many  investi- 
gators, concerning  the  immediate  and  delayed  after-effects  associated 
with  inhalation  anesthesia.  Observations  made  by  Clover  and  others  of 
the  earliest  workers  in  this  field  tended  to  prove  that  the  after-effects  are 
lessened  when  a  warmed  vapor  is  used.  Subsequent  laboratory  experi- 
ments and  clinical  observations  have  amply  verified  these  findings. 

A  warmed  vapor  (provided  it  is  not  too  warm)  gives  rise  to  less  irri- 
tation to  the  air  passages,  and  thus  decreases,  the  danger  of  post-anes- 
thetic bronchitis  and  pneumonia. 

The  warmed  vapor,  being  less  irritating  to  the  buccal  mucous  mem- 
branes, causes  less  stimulation  of  the  salivary  and  mucous  glands,  and 
consequently  there  is  a  less  profuse  secretion  of  saliva  and  mucus  than 
is  apt  to  occur  when  cold  vapor  is  administered.  The  anesthesia,  there- 
fore, is  accompanied  and  followed  by  less  nausea  and  vomiting  than 
occur  as  a  consequence  of  the  hypersecretion  of  these  nauseating  fluids 
when  a  cold  vapor  is  employed.  This  observation  is  particularly  striking 
with  ether. 

The  late  after-effects,  such  as  acid  intoxication  and  its  consequences, 
have  received  voluminous  attention  from  many  observers,  among  whom 
there  is  no  unanimity  regarding  the  cause  of  these  manifestations. 
Doubt  has  been  expressed  by  some  concerning  the  existence  of  such 
sequels.  Idiosyncrasy,  gastro-intestinal  disturbances,  preexisting  met- 
abolic fault,  nervous  influence,  and  failure  of  complete  elimination  of 
the  agent  from  the  blood,  with  consequent  degenerative  changes  in  the 
vascular  elements  and  other  tissues,  are  some  of  the  explanations  offered. 

Whatever  the  cause,  it  seems  to  be  fairly  well  agreed  that  acidosis, 
and  other  late  after-effects,  occur  in  a  certain  proportion  of  cases. 

With  the  administration  of  warmed  anesthetics,  according  to  the 
method  described  in  the  section  on  Administration  (p.  63),  both  the 
immediate  and  the  delayed  after-effects  are  reduced  to  a  minimum.^ 

Experiments  on  Warming  Ether. — It  is  maintained  by  some  investi- 

^  It  has  been  known  for  a  long  time  that  during  chloroform  and  ether  anes- 
thesia the  temperature  of  the  body  is  lowered,  and  the  opinion  has  been  ad- 
vanced that  the  great  fall  of  temperature  may  be  partially  responsible  for  the 
development  of  pneumonia. 

A.  Lawen  {Miinch.  med.  Woch.,  1911,  2097)  has  studied  the  question  as  to 
whether  post-operative  pneumonia  can  be  avoided  by  warming  the  anesthetic 
prior  to  its  inhalation.  He  therefore  experimented  with  an  apparatus  by  means 
of  which  the  chloroform  and  ether  vapors  could  be  warmed.  His  results  show 
that  pneumonia  cannot  be  thus  avoided,  though  he  does  not  doubt  that  a  small 
proportion  of  cases  of  post-operative  pneumonia  may  be  prevented  by  the  pro- 
posed modification  of  the  method  of  inhalation  anesthesia.  He  considers  that 
the  warmed  anesthetics  are  only  suitable  for  prolonged  abdominal  operations, 
and  for  operations  in  which  the  wounds  are  extensive,  such  as  in  amputation  of 
the  breast.  He  also  considers  the  warmed  anesthetic  to  be  indicated  for  patients 
who  have  lost  much  blood  or  who  are  suffering  from  shock. 


GENERAL  PHYSIOLOGY  OF  INHALATION  ANESTHESIA     71 

gators  that  ether  vapor  cannot  l)e  heated.  iSeelig'  eondueted  a  .series  of 
experiments  for  the  purpose  of  estahlishing  the  (;orrcctncss  of  this  view. 

The  authors  of  this  hook,  wishing  to  settle  the  disputed  point  with 
reference  to  the  possibility  of  heating  anesthetic  vapors,  undertook  a 
series  of  experiments  to  determine  whether  the  vapor  is  really  warmed  by 
being  passed  through  a  coil  ten  feet  long  placed  in  a  heater,  according  to  a 
method  in  actual  practice. 

A  rubber  tube,  of  the  same  length  as  that  used  in  actual  practice, 
with  a  thermometer  placed  at  one  end  and  also  a  tliermometer  for  room 


Fig.  11. — Gwathmey's  Vapor  Apparatus  with  the  Tube  Leading  from  the  Heater 
AS  IN  Actual  Practice,  a.  Compressed  air;  b.  Gwathmey  anesthetic  apparatus; 
bi.  ether  container;  bh.  water;  b.  ether  vapor  exit;  c.  vapor  heating  apparatus;  ci.  elec- 
tric hot  plate;  c".  asbestos  mat  insulator;  c"i.  water  bath;  c'^.  thermolite  heater; 
c'.  inlet  to  heater;  d.  exit  for  heated  vapor;  e.  asbestos  insulator;  f.  60  cm.  rubber 
tube;  G.  glass  T-tube;  h.  200°  C.  thermometer;  i.  drain;  k.  thermometer  for  room 
temperature.     (From  S.  G.  Davis.) 


temperature,  was  employed  (see  Fig.  11).  Compressed  air  was  passed 
through  for  one  hour. 

(Joss  -  has  found  that  ether  cools  the  air  inhaled  33°  to  44°  F.  below 
the  temperature  of  the  room.  The  cooled  air  undoubtedly  lowers  the 
resisting  powers  of  the  cilia  of  the  ciliated  epithelium  lining  the  upper 
air  passages  when  these  passages  become  chilled.  Infection  is  more 
likely  to  find  its  way  into  the  finer  air  passages  as  salivation  increases 
under  the  chilled  anesthetic.) 

These  experiments  gave  the  following  data: 

From  Table  1  it  will  be  seen  that  the  temperature  of  the  ether 
vapor  can  be  raised  to  any  degree  desired  and  maintained  at  that  point. 
The  vapor  may  be  heated  by  difl^erent  methods,  but  this  is  probably  one 
of  the  easiest,  as  with  this  simple  apparatus  one  is  not  dependent  upon 
electricity  as  the  heat  source. 

^Seelig,  M.  G.:  "The  Fallacy  of  Warmed  Ether  Vapor,"  Inter.  Med.  J., 
Sept.,  1911;  see  also.  Cotton  and  Boothby:  "The  Uselessness  of  Warming 
Anaesthetic  Vapor,"  Surg.,  Gyn.  and  Obst.,  Dec,  1912. 

^Mitteil.  a.  d.  Grenzgeh.  d.  Med.  u.  Chir.,  22,  No.  40. 


72 


ANESTHESIA 


TABLE  1 — Using  Rubber  Tube  with  Continuous  Flow 

Amount  of  ether  taken,  4  ounces. 
Amount  of  ether  used,  3.5  ounces  in  one  hour. 
Compressed  air  flow,  continuously  through  ether. 
Room  temperature,  24°  C,  Nov.  4,  1911. 


After    5  minutes . . 

.  29.25°  C.  ] 

After  10  minutes . . 

.  29° 

After  15  minutes. . 

.  31° 

After  20  minutes . . 

.  31° 

Ether  container 

Temperature, 

After  25  minutes . . 

.  30° 

warmed  as  is 

65  cm.  from  heater  - 

After  30  minutes . . 

.  30.25° 

necessary. 

(usual  distance) 

After  35  minutes.  . 

.  32.25° 

Heated  ether 

After  40  minutes . . 

.  32° 

container. 

After  45  minutes . . 

.  32° 

After  50  minutes . . 

.  30° 

.  After  55  minutes . . 

.  30°            J 

In  order  to  determine  the  temperature  of  ether  at  different  distances 
from  Davis'  heater,  which  was  attached  to  the  Gwathmey  three-bottle 
vapor  inhaler,  a  series  of  experiments  were  conducted  in  the  chemical 


Fig.  12. — Gwathmey's  Vapor  Inhaler  with  Heating  Apparatus,  f.  Glass  tube  di- 
vided into  six  parts  of  10  cm.  each;  f.'  thermometers;  i.  drain;  k.  thermometer  for 
room  temperature;  e.  asbestos  insulator. 

laboratories  of  the  College  of  the  City  of  New  York  by  the  authors.    The 
experiments  were  carried  out  by  Mr.  W.  A.  Hamor. 

A  special  glass  tube  was  constructed  with  uniform  side  tube  openings 
10  cm.  apart,  into  which  thermometers  were  inserted  (see  Fig.  12). 
At  the  side-tube  exits  and  over  the  thermometers,  a  tightly  fitting  rubber 
collar  was  placed  to  prevent  leakage.  The  glass  tube  was  attached  to  a 
thermolite  coil-heater,  immersed  in  a  water  bath,  which  was  kept  at  the 


GENERAL  PHYSIOLOGY  OF  INHALATION  ANESTHESIA     73 

boiling  point  by  an  electTic  liot-plate.  The  Gwathmey  vapor  apparatus 
was  attached  to  this  heater;  compressed  air  was  passed  through  the 
ether  bottle,  the  resulting  ether-vapor-air  stream  then  passing  through 
the  water-bottle  of  the  vapor-apparatus,  and  finally  through  the  heater 
and  the  tube  into  which  were  inserted  thermometers.  Eeadings  were 
made  every  five  minutes  for  one  hour  and  the  room  temperature  was 
noted  at  the  same  time.     The  following  table  shows  the  results: 


TABLE  2 — Using  Glass  Air  Condenser  Attached  to  Heater 

Amount  of  ether  taken,  4  ounces. 

Amount  of  ether  used,  3  ounces. 

Compressed  air  flow,  continuously  through  ether. 

Room  temperature,  23.5°  C. 

Temperature  in  Degrees  Centigrade  at  Various  Distances 
November  4,  1911 


Time  in  minutes 

5 

10 

15 

20 

25^ 

30 

35 

40 

45 

50 

55 

60 

From  heater: 

At  10  cm.... 

36 

40.5 

42 

38.5 

40 

41 

40 

44 

44.5 

45 

16 

47 

At  20  cm.... 

27 

33.5 

34 

32 

33.5 

33.5 

33 

35 

35 

34.5 

34.5 

35 

At  30  cm.... 

25 

30.5 

30 

29 

30.5 

30 

29 

31 

30.5 

30.5 

30 

30 

At  40  cm.... 

24 

28 

28 

28 

28 

28 

27 

29 

29 

29 

29 

29 

At  50  cm 

24 

26.5 

26 

26 

26.5 

26 

26 

28 

28 

28 

27.5 

27.5 

At  60  cm.  .. 

24 

26 

25.5 

25 

26 

25.5 

25.5 

26.5 

26.5 

26.5 

26.5 

26.5 

'  Eearrangement  of  flow. 

Boothby  ^  has  maintained  that  "warmed  ether  per  se"  possesses  no 
merits  over  "cold  ether,"  that  is,  not  warmed.  According  to  him,  the 
concentration  of  the  ether  vapor  in  the  air  passing  over  or  through  the 
ether  varies  with  the  temperature  of  the  liquid  ether  itself,  that  is,  as 
the  ether  evaporates  more  or  less  rapidly  the  temperature  of  the  liquid 
is  lowered  with  a  decrease  in  concentration  of  ether  vapor  in  the  effluent 
mixture  from  the  vaporizer,  hence  the  patient  does  not  get  enough  ether. 
The  specific  heat  of  ether  vapor  is  very  small,  consequently  the  mixture 
quickly  acquires  room  temperature.  Air,  the  volume  of  which  per 
minute  was  determined  by  a  Bohr  meter,  was  passed  over  the  surface  of 
ether  placed  in  a  Wolff  bottle,  wherein  the  ether  presented  a  surface 
area  of  about  50  sq.  cm.  The  temperature  of  the  liquid  ether  was  noted 
with  a  thermometer  immersed  about  1.5  cm.  in  the  ether.    The  tempera- 

^  Discussion  before  the  New  York  Society  of  Anesthetists,  1913.  Copies  of  the 
curves  were  courteously  provided  by  Dr.  Boothby. 


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GENERAL  PHYSIOLOGY  OP  INHALATION  ANESTHESIA      75 


ture  of  the  air-ether  mixture  coming  from  tlie  apparatus  was  noted  in  a 

Waller  gas  balance,  which  served  to  indicate  tlie  coinposiiioii  of  the  m\x- 

40  r 


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Fig.  13d. — Boothby  Curve. 

ture.  The  curves  obtained  by  Boothby  are  given  herewith,  sufficiently 
labeled  to  be  self-explanatory.  In  connection  with  Boothby's  con- 
clusions the  following  facts  demand  con- 
sideration : 

(1)  Ether  given  by  the  "vapor 
method"  does  not  go,  mixed  with  air  or 
oxygen,  first  into  a  ballon  or  reservoir 
subsequently  to  be  breathed  by  the  pa- 
tient, but  directly  to  the  patient,  hence 
it  enters  the  air  passages  before  it  has 
had  time  to  acquire  room  temperature. 

(See  Authors'  Experiments,  p.  G3.) 

(2)  Ether  administered  in  any  way 
by  inhalation  eventually  reaches  body 
temperature  in  the  lungs.  The  total 
shortage  of  heat  is  not  taken  from  the 
entire  surface  of  the  lungs,  but  is  local- 
ized in  the  bronchial  passages,  that  is, 
there  is  local  chilling  or  heating  if  the 
vapor  be  too  hot. 

(3)  Davis  has  shown  clinically  that 
very  beneficial  results  are  had  even  if  the 
vapor  be  produced  from  cold  ether,  pro- 
vided it  is  subsequently  warmed.  (See 
Chapter  on  Administration,  p.  67.) 


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Fig.  13e. — Boothby  Curve. 


76  ANESTHESIA 

From  the  preceding  table  it  will  be  seen  that  ether  vapor  may  be 
heated,  and  the  heating  maintained  for  any  length  of  time  and  delivered 
to  a  patient  as  jjredetermined  by  the  anesthetist.  For  instance,  we  see 
that  at  60  cm.  from  the  heater  at  the  end  of  sixty  minutes  the  tem- 
perature was  three  degrees  C.  higher  than  the  room  temperature.  About 
the  same  amounts  of  ether  and  air  were  used  in  this  experiment  as  are 
usual  in  practice. 

Air  was  passed  through  the  ether  and  water-bottle  of  the  vapor- 
apparatus  without  the  heater  and  readings  kept  uj)  for  forty-five  min- 
utes.   The  following  table  gives  the  result: 


TABLE  3 — Non-Warmed — Room  Temperature 

Room 
temperature 

After    5  minutes 27.5°  C.  28°  C. 

After  10  minutes 27°  28° 

After  15  minutes 27.5°  28° 

After  20  minutes 27.5°  28° 

After  25  minutes 27.5°  28° 

After  30  minutes 27.5°  28° 

After  35  minutes 27°  27° 

After  40  minutes 27°  27° 

After  45  minutes 27°  27° 

From  this  table  it  will  be  seen  that  at  the  end  of  forty-five  minutes 
the  vapor  was  approximately  sixteen  degrees  F.  below  blood  temperature. 

The  results  show  that  ether  vapor  can  be  heated  easily  and  inexpen- 
sively, and  that  it  can  be  delivered  to  the  patient  at  any  desired  tem- 
perature, within  limits,  by  placing  the  heater  or  warming  device  at 
different  distances  from  the  patient's  face. 

Effects  of  Moisture. — Since  1909,  Gwathmey  has  employed  warmed 
moist  vapors  for  pulmonary  anesthetics.  Baskerville  ^  has  called  atten- 
tion to  the  importance  of  moisture,  among  other  factors  which  influence 
the  course  of  anesthesia.  "It  has  been  shown,^'  he  says,  "that  the  admin- 
istration of  moist  ether,  free  from  aldehyd,  at  body  temperature,  is 
rarely  followed  by  nausea  (less  than  ten  per  cent),  and  the  usual  strain 
upon  the  kidneys  is  not  observed." 

"Nitrous  oxid,  ether,  and  chloroform,"  he  continues,  "each  exerts  its 
specific  physiological  effect  in  producing  anesthesia  without  asphyxia- 
tion, provided  the  respiratory  and  cardiac  functions  are  approximately 
normal.  This  may  be  and  is  being  accomplished  by  administering  these 
gasified  drugs  with  sufficient  oxygen  not  to  interfere  seriously  with  the 

^Baskerville:     "The  Chemistry  of  Anesthetics,"  Science,  n.  s.,  Aug.  11,  1911. 


GENERAL  PHYSIOLOGY  OF  INHALATION  ANESTHESIA  •   77 

normal  function  of  the  hemoglobin  of  carrying  oxygen  to  the  capillaries, 
and  sustaining  cardiac  stimulation,  and  by  maintaining  the  usual  con- 
centration of  carbon  dioxid  in,  and  providing  its  regular  elimination 
from,  the  blood;  for  it  is  the  respiratory  stimulant  (Yaiidall  Hender- 
son). Other  factors  involved  are  temperature  and  moisture.  The  anes- 
thetics are  carried  into  the  system  at  body  temperature.  This  may  be 
and  is  being  accomplished  by  warming,  and,  in  the  case  of  ether  and 
anesthetic  chloroform,  by  passing  the  vapor  through  heated  water,  which, 
at  body  temperature,  not  only  removes  the  oxidation  products,  but  sat- 
urates the  gas  with  moisture  (Gwathmey  method).  The  osmotic  action 
of  the  alveolar  cells  is  thus  affected  only  to  the  extent  of  the  density 
of  the  gases  introduced  into  the  lungs,  and  not,  as  normally  is  the  case, 
by  temperature  (always  lower)  and  desiccation  as  well." 

Briining,^  j&nding  compressed  air  relatively  much  more  harmful  to 
the  lungs  than  pure  oxygen,  or  air  in  the  Geppert  apparatus,  instituted 
experiments  to  determine  the  factors  which  cause  the  difference  in  effect. 
Differences  in  the  temperature  could  not,  in  his  oiDinion,  be  responsible, 
as  repeated  measurements  always  showed  25°  to  30°  in  all  the  gases, 
uniformly.  For  the  same  reason,  the  strength  of  the  air  current  could 
not  be  responsible.  The  remaining  factor  was  the  content  in  moisture 
of  the  different  gases. 

The  oxygen  and  the  air  from  the  steel  cylinders  had  only  a  relative 
humidity  of  10-15  per  cent.  These  values  are  so  low  that  the  sojourn  in 
such  dry  air  would  normally  be  harmful  for  man  and  might  lead  to 
pneumonia.  We  feel  most  comfortable  in  air  which  contains  between  40- 
60  per  cent  moisture. 

Inspiration  or  Compressed  Air  With  Water  Vapor. — In  a 
series  of  experiments  upon  mice,  different  degrees  of  moisture  were 
obtained  by  allowing  water  to  drip  into  the  air  stream.  The  desired 
humidity  was  produced  in  such  a  way  that  water  was  poured  into 
the  ether-flask  of  the  Eoth-Drager  apparatus,  with  a  regulated  outflow 
of  the  water,  so  that,  after  some  practice,  the  gas-mixture  would  be 
maintained  fairly  constant  at  the  desired  humidity.  (See  Table  4, 
page  78.) 

The  table  shows  that  the  lungs  presented  nothing  pathological,  with 
moisture  contents  of  the  air  from  50-70  per  cent.  Even  after  three 
breathing  periods  no  changes  were  found.  But  when  the  moisture  con- 
tents were  diminished  below  40  per  cent,  or  increased  to  100  per  cent, 
hemorrhages  at  once  made  their  appearance.  As  the  air  in  Geppert's 
apparatus  contains  approximately  95  per  cent  relative  moisture,  the 
occurrence  of  slight  pulmonary  lesions  is  readily  understood.    The  entire 

^  Briining,  A. :  "  Studien  zur  Narkosenfrage,  ins  besondere  liber  die  An- 
wendung  von  Sauerstoff  und  komprimierter  Luft, "  Deut.  Z.  Cliir.,  1911-12,  113, 
532. 


78  •  ANESTHESIA 

TABLE  4 — Inspiration  of  Compressed  Air  With  Water  Vapor 
Mouse 


No. 

Duration 
of  exp. 

Time  to 

sacrifice 

or  second 

exp. 

Second 
exp. 

Time  to 
sacrifice 

Macroscopical 
lung  findings 

Moisture 
contents 

of 

air 

36 

hours 

at 
once 

Nothing 
pathological 

70% 

45 

IM 

hours 

at 
once 

. 

Some  hyperemia, 
otherwise  normal 

35% 

41 

2 
hours 

at 
once 

Normal 
appearance 

55% 

42 

2 

hours 

7 
hours 

Some  hyperemia, 
otherwise  normal 

55% 

37 

hours 

19K 
hours 

2 

hours 

at 
once 

Nothing 
pathological 

70.65% 

38 

hours 

193^ 
hours 

2 
hours 

22 

hours 

free 

3d  experiment, 

^  hour, 
killed  at  once. 
Lungs  normal 

70.65  +  % 

46 

hours 

at 
once 

Marked  hyperemia, 
some  hemorrhages 

100% 

experimental  series  justifies  the  conclusion  that  too  much  dryness  and 
too  much  moisture  are  injurious  for  the  lungs ;  but  when  these  extremes 
are  avoided,  oxygen,  compressed  air,  and  the  Geppert  apparatus  can  be 
equally  recommended. 

A  later  series  of  experiments  showed  similar  pulmonary  changes  from 
artificially  dried  air,  as  after  the  breathing  of  air  that  had  been  com- 
pressed; therefore,  the  cause  of  the  hemorrhages  cannot  be  referable  to 
any  abnormal  composition  of  the  air  in  the  steel  cylinders. 

It  still  remains  to  be  shown  why  the  lungs  are  less  injured  by  oxygen, 
although  it  has  only  a  relative  moisture  content  of  10-15  per  cent,  than 
by  the  equally  dry  air;  and  also  why  the  dryness  as  such  can  act  harm- 
fully. Injuries  through  very  dry  air  are  explained  by  Briining  as 
follows : 

The  alveolar  epithelia  are  lined  with  a  thin  layer  of  water,  which  is 
derived  from  the  blood,  and  by  its  constant  evaporation   invests  the 


GENERAL  PHYSIOLOGY  OE  INHALATION  ANESTHESIA      79 

expired  air  with  its  high  content  of  moisture.  In  this  thin  hiyor,  oxy- 
gen is  dissolved  and  is  carried  from  here  hy  diffusion  to  tlic  hlood 
corpuscles.  When  the  moisture  contents  of  the  inspired  air  are  ahiior- 
mally  low,  the  water  evaporates  very  rapidly,  the  capillaries — which  are 
exposed  for  a  large  part  of  their  circumference — dry  out,  and  permit 
the  blood  corpuscles  to  pass  between  them.  In  addition,  the  secretion- 
pressure  for  oxygen  drops,  through  the  lesion  of  the  endothelia,  and  the 
organism  reacts  by  an  increased  blood  supply — hyperemia — in  order  to 
take  up  the  same  quantity  of  oxygen  through  an  increased  surface.  In 
the  further  course,  inflammatory  manifestations  on  the  bronchi  make 
their  appearance.  The  slight  bloody  extravasates,  on  breathing  of  pure 
oxygen,  are  interpreted  by  Brlining  as  a  chemical  injury.  The  passage 
through  a  dried-out  cell  being  necessarily  hindered,  the  oxygen  remains 
for  a  longer  time  in  contact  with  the  protoplasm;  or  the  cell  must  exert 
an  increased  activity,  in  order  to  accomplish  the  same  functional  results. 
Consequently,  there  are  over-stimulation  and  over-taxation  of  the  cell. 

On  breathing  an  air  saturated  with  water-vapor,  the  evaporation  of 
the  alveolar  moisture  proceeds  more  slowly,  the  water-layer  at  the  walls 
is  likely  to  be  thicker  and  to  stimulate  the  cells  by  its  constant  oxygen- 
contents.  The  secretion-pressure  of  the  endothelia  is  normally  subject 
to  constant  fluctuations,  in  the  opinion  of  Briining,  corresponding  to 
inspiration  and  expiration,  so  that  the  cellular  protoplasm  regularly 
enjoys  a  brief  rest. 

The  slightness  of  the  pulmonary  changes,  on  the  breathing  of  pure 
oxygen,  is  attributed  by  Briining  to  the  increased  oxygen  partial  pres- 
sure, which  facilitates  diffusion  and  secretion. 

Briining  concluded,  from  his  experiments,  that,  in  the  brief  time  of 
a  general  anesthesia,  injury  to  the  lungs  is  to  be  feared  only  under  em- 
ployment of  compressed  air  from  the  steel  cylinders,  and  that  this  can 
be  avoided  by  moistening  the  air  to  about  50  per  cent. 

The  examination  of  the  lungs,  after  the  inhalation  of  the  different 
gases,  showed  very  considerable  difference.  After  the  inspiration  of 
compressed  air,  the  lungs  of  mice  invariably  showed  extensive  hemor- 
rhages and  bronchitic  symptoms,  which  were  especially  evident  after 
long  duration  of  the  experiment,  or  several  repetitions.  The  air  in  Gep- 
pert's  apparatus  and  oxygen  have  a  similar  effect,  but  to  a  much  less 
degree.  The  lesions  are  dependent  upon  the  relative  moisture  of  the  air, 
and  can  be  avoided  by  moistening  the  inspiration  air  with  water  vapor, 
up  to  50-80  per  cent.  Too  high  a  vapor-saturation  acts  in  the  same 
sense  as  too  much  dryness.  The  absence  of  grave  lesions  in  oxygen- 
breathing,  in  spite  of  low  moisture,  is  referable  to  specific  properties  of 
the  oxygen. 

Briining's  experiments  led  to  the  following  practical  conclusions : 
(1)    General   anesthesia  by  means   of   the   Eoth-Drager   apparatus. 


80  ANESTHESIA 

under  utilization  of  oxygen,  is  preferable  to  general  anesthesia  under 
employment  of  compressed  air,  unless  the  moisture  of  the  air  is  artifi- 
cially increased  to  50  per  cent. 

(2)  General  anesthesia  with  oxygen  is  equivalent  to  general  anes- 
thesia by  means  of  the  Geppert  apparatus. 

(3)  In  the  accidents  of  general  anesthesia,  artificial  respiration  alone 
is  always  efficient  for  the  introduction  of  enough  oxygen  into  the  body; 
the  breathing  of  pure  oxygen  offers  no  advantages. 

(4)  The  majority  of  the  advantages,  claimed  for  oxygen,  are  only 
due  to  the  more  accurate  dosage  by  means  of  the  modern  anesthetic 
apparatus. 

Combining  Oxygen  with  the  Agent. — In  1904,  experiments  were 
conducted  (J.  T.  G.)^  to  determine  the  value  of  oxygen,  as  compared 
with  atmospheric  air,  in  combination  with  different  anesthetic  agents, 
attention  having  been  particularly  directed  to  the  subject  by  certain 
statements  made  by  Hewitt. 

With  reference  to  nitrous  oxid  Hewitt  says :  "It  is  now  established 
beyond  all  doubt  that,  by  employing  certain  percentages  of  atmospheric 
air  with  nitrous  oxid,  a  better  form  of  anesthesia  can  be  obtained  than 
with  the  undiluted  gas,  and  that,  by  using  oxygen  instead  of  atmospheric 
air,  a  still  better  form  of  anesthesia  is  obtainable.'^ 

Concerning  chloroform,  however,  Hewitt's  views  are  not  so  favorable : 
"It  is  doubtful  whether  there  is  any  great  advantage  in  the  addition  of 
oxygen  to  atmospheric  air  during  the  administration  of  chloroform,  save 
perhaps  in  cases  in  which  much  respiratory  difficulty  is  present,  and  in 
these  cases  the  use  of  any  tightly  fitting  inhaling  apparatus  would  almost 
certainly  neutralize  the  theoretical  advantages  of  using  oxygen." 

Eeasons  for  Using  Oxygen.— The  advocacy  of  the  combination  of 
oxygen  with  inhalation  anesthetics  is  based  largely  upon  the  experiments 
of  Priestley,  Demarquay,  Eichet,  Paul  Bert,  and  others,  and  upon  the 
clinical  observations  of  Andrews,  of  Chicago,  with  nitrous  oxid,  and  of 
Neudorfer,  of  Vienna,  with  chloroform. 

The  reason  for  giving  oxygen  with  nitrous  oxid  is  explained  by 
Hewitt "  in  the  following  manner :  "A  mixture  of  40  per  cent  of  air 
and  GO  per  cent  of  nitrous  oxid  would  contain  about  8  per  cent  of 
oxygen  and  32  per  cent  of  nitrogen;  and  although  the  8  per  cent  of 
oxygen  would  be  sufficient  to  nearly  or  completely  preserve  the  natural 
color  of  the  patient's  face,  and  to  suppress  clonic  muscular  spasm,  the 
60  per  cent  of  nitrous  oxid  would  be  insufficient  to  produce  tranquil 
anesthesia.  If,  however,  instead  of  using  air  for  oxygenating  purposes, 
we  employ  oxygen,  we  shall  be  able  to  replace  the  32  per  cent  of  useless 

^Gwathmey,   J.   T. :      "Experiments    to    Determine   the   Value    of    Oxygen   in 
Combination  with  the  Different  General  Anesthetics,"  Med.  Bee,  Nov.  19,  1904. 
=  Hewitt:     " Anesthetics, "  4th  ed.,  311. 


GENERAL  PHYSIOLOGY  OF  INHALATION  ANESTHESIA     81 

nitrogen  by  a  corresponding  quantity  of  useful  nitrous  ox  id,  and  the 
proportion  of  the  latter  will  now  rise  to  92  per  cent." 

From  this  it  will  be  seen  that  there  is  a  physiological  basis  for  the 
combination  of  oxygen  with  nitrous  oxid.  Clinical  experience  bears  out 
the  theoretical  calculations. 

The  ground  for  using  oxygen  with  chloroform  or  the  "C.E.  -  mix- 
ture," ether,  or  ethyl  chlorid,  is  as  well  founded,  theoretically  and  clin- 
ically, as  is  that  of  its  combination  with  nitrous  oxid. 

Normally  for  every  volume  of  inspired  air,  4.8  per  cent  of  oxygen  is 
abstracted,  4.3  per  cent  of  carbon  dioxid  being  substituted.  During 
anesthesia  the  blood  becomes  more  and  more  venous  from  an  obstruction 
to  the  entrance  of  p,ir  into  the  lungs,  and  from  the  blood  failing  to  take 
from  the  air  its  usual  supply  of  oxygen.  Asphyxia  is  produced  more  by 
the  diminution  of  oxygen  than  by  the  increased  amount  of  carbon 
dioxid.  According  to  Patton,'^  Eumph  found  a  decrease  of  40  per  cent 
of  carbon  dioxid  eliminated  in  the  respiratory  exchanges,  and  Eichet 
found  a  decrease  of  50  per  cent  in  the  elimination  of  carbon  dioxid  in 
chloralized  dogs. 

Bert's  experiments  with  chloroform  show  a  progressive  diminution  in 
oxygen  absorbed,  and  of  carbon  dioxid  given  off.  Lorrain  Smith  has 
shown  that  dyspnea  from  changes  in  the  gaseous  composition  of  the 
blood  may  be  due  to  a  deficiency  of  oxygen. 

Eichet  states  that  blood  which  contains  an  anesthetic  in  solution 
preserves,  when  shaken  with  ether,  its  full  ability  for  fixing  oxygen. 
Irregular  forms  of  breathing  may  also  occur  from  too  little  oxygen,  as 
in  the  closed  administration  of  volatile  agents;  or,  from  carbon  dioxid 
dyspnea,  as  in  rebreathing  during  the  administration. 

The  experiments  of  Priestley  and  others,  of  placing  small  animals 
under  two  different  receivers,  one  filled  with  oxygen  and  the  other  with 
air,  showed  that  those  under  the  oxygen  receiver  survived  twice  as  long 
as  the  others ;  also,  that  the  death  of  birds  in  the  oxygen  was  not  accom- 
panied by  convulsions  as  was  that  of  birds  that  died  in  the  air ;  further- 
more, that  the  heart  retained  its  irritability  for  several  hours  when  death 
took  place  in  oxygen, 

Demarquay  ^  immersed  two  kittens  in  water  and  kept  them  there 
until  they  had  lost  consciousness.  One  had  previously  been  confined  for 
twenty  minutes  in  a  glass  case,  containing  two  parts  of  oxygen  and  one 
of  air,  and  the  other  had  breathed  only  atmospheric  air.  On  removing 
them  from  the  water  there  was  only  a  slight  movement  of  the  lower 
jaw.    At  the  end  of  five  minutes  and  a  half,  the  superoxygenated  kitten 

^Patton,  Joseph  M. :     "Anesthesia  and  Anesthetics,"  1903. 

^  Demarquay,  J.  N. :  "  Essay  on  Medical  Pneumatology :  Physiological, 
Clinical,  and  Therapeutic  Investigation  of  the  Gases,"  Translated  by  Samuel  S. 
Wallian,  A.M.,  M.D.,  1889. 


82  .  ANESTHESIA 

arose,  totteringly  walked  around,  and  made  an  uneventful  recovery.  The 
other  partially  recovered  at  the  end  of  fifteen  minutes,  but  died  the  next 
day.  These  experiments  were  repeated  a  number  of  times,  and  always 
with  the  same  result. 

The  above  experiments,  illustrating  the  value  of  oxygen  as  compared 
to  air,  have  been  practically  paralleled  by  Gwathmey.  Eegardless  of  the 
anesthetic  used,  animals  have  lived  twice  as  long  with  oxygen  as  with 
air.  With  oxygen  the  heart  continued  to  beat  long  after  respiration 
ceased. 

It  may  be  added  here  that  the  heart  always  continued  to  beat  a 
variable  length  of  time  after  respiration  ceased,  whether  air  or  oxygen 
was  used,  and  with  all  anesthetics.  Greater  success  in  reviving  them 
after  cessation  of  respiratory  and  cardiac  activity  has  come  with  the  use 
of  oxygen  than  with  air. 

The  after-effects  produced  upon  animals  have  been  carefully  studied. 
Inasmuch  as  oxygen  is  constantly  employed  clinically,  with  both  chloro- 
form and  ether,  it  may  be  stated  positively  that  the  after-effects  are 
reduced  to  a  minimum. 

Experiments  with  Animals. — In  the  experiments  conducted  by 
Gwathmey  a  closed  mask  with  an  expiratory  valve,  with  the  light 
rubber  bag  just  behind  the  mask,  was  used.  This  animal  mask 
was  a  cone-shaped  brass  cylinder  3^/2  inches  in  diameter  at  the  base  and 
1%  inches  at  the  apex.  Over  the  base,  or  open  end,  were  stretched  two 
thicknesses  of  thin  rubber,  fastened  around  the  margin  of  the  cone  by  a 
rubber  band.  A  small  opening  1^  inches  in  diameter  was  cut  in  the 
center,  into  which  the  animal's  nose  was  placed.  The  technique  in  each 
instance  was  as  nearly  as  possible  the  same,  the  same  amount  of  anes- 
thetic being  used  in  each  experiment,  and  the  flow  of  air  and  oxygen 
being  regulated. 

To  make  these  experiments  as  accurate  as  possible,  over  one  hundred 
animals  were  killed,  and  the  average  time  recorded.  It  has  not  been 
deemed  necessary  to  enter  into  details  of  the  exact  weight,  age,  size,  and 
physical  condition  of  each  animal.  It  may  be  said,  however,  that  ani- 
mals as  nearly  alike  as  possible  in  all  essential  respects  were  selected  for 
each  comparison.  The  results,  in  detail,  as  will  be  seen  from  the 
tables  on  pages  84  and  85,  varied  in  accordance  with  the  individual 
characteristics  and  conditions ;  as  a  whole,  they  confirmed  the  claim  that 
the  use  of  oxygen  in  connection  wi.th  any  form  of  anesthetic  practically 
eliminates  the  percentage  of  danger  which  has  hitherto  been  recognized 
as  inseparable  from  the  practice  of  anesthesia. 

In  order  to  determine  the  difference  in  toxicity  of  the  drugs  used, 
the  time  was  taken  from  the  application  of  the  mask  to  the  stoppage  of 
the  heart.  As  the  toxic  effects  came  on  so  rapidly,  observations  on  the 
pulse,  respiration,  and  blood  pressure  were  of  little  value. 


GENERAL  PHYSIOLOGY  OF  INHALATION  ANESTHESIA      83 

Twenty-six  animals  were  killed  with  chloroform  and  air,  the  average 
time  being  nine  minutes;  the  shortest  time,  three  minutes;  the  longest, 
seventeen  minutes.  Thirty-eight  animals  were  killed  with  chloroform 
and  oxygen,  the  average  time  being  twenty-one  minutes;  the  shortest 
time,  five  minutes;  and  the  longest,  one  hour  and  a  half.     (See  p.  84.) 

With  ether  and  air  twelve  were  killed,  the  average  time  being  nine- 
teen minutes,  the  shortest  fifteen,  and  the  longest  thirty-three  minutes. 
Seven  were  killed  with  the  same  anesthetic  and  oxygen,  the  average  time 
being  thirty-five  minutes,  the  shortest  twenty-five  minutes,  and  the  long- 
est one  hour.     (See  p.  85.) 

With  one  part  of  chloroform  and  two  parts  of  ether,  thirteen  animals 
were  killed,  six  with  air  and  seven  with  oxygen.  The  average  time  with 
air  was  nineteen  minutes ;  with  oxygen,  thirty-five  minutes.  The  short- 
est time  with  this  mixture  and  air  was  fifteen  minutes ;  the  longest  time, 
thirty  minutes.  The  shortest  time  with  oxygen  was  sixteen  minutes; 
the  longest,  one  hour  and  ten  minutes.     (See  p.  85.) 

From  the  above  it  will  be  seen  that  chloroform  with  oxygen  is  safer 
than  chloroform  with  air,  and  is  also  safer  than  any  of  the  other  general 
anesthetics  with  air.  This  means  that,  instead  of  giving  a  very  high 
mortality,  chloroform  with  oxygen  is  as  safe  as  ether  with  air. 

From  the  above  experiments  and  clinical  observations  it  may  be 
deduced  that  oxygen  increases  the  value  of  all  anesthetics  in  rendering 
their  administration  safer  to  the  patient  without  decreasing  the  anes- 
thetic quality. 

In  a  recent  paper  Briining  ^  discusses  the  value  of  oxygen  employed 
in  connection  with  narcotics.  He  states  that  oxygen  alone  will  not 
account  for  the  improved  narcosis  witnessed  in  the  administration  of 
anesthetics  with  perfected  apparatus.  He  attributes  this  to  the  exact 
and  equal  dosage,  and  maintains  that  compressed  air  is  equally  useful 
if  the  moisture  of  the  lungs  is  artificially  increased  to  50  per  cent.  (See 
p.  86.) 

In  accidents  in  narcosis,  according  to  Briining,  artificial  respiration 
alone  is  always  sufficient  to  introduce  oxygen  into  the  body.  Pure  oxy- 
gen inhalation  offers  no  advantage.  The  smaller  proportion  of  anesthetic 
needed  when  oxygen  is  employed  he  attributes  solely  to  the  improved 
dosage  facilities  with  the  Eoth-Drager  apparatus.  The  minimizing  of 
the  after-effects,  such  as  headache,  vomiting,  etc.,  he  attributes  to  the 
diminished  amount  of  chloroform  employed.  The  employment  of  oxygen 
inhalation  after  narcosis  is  of  no  special  value,  as  deep  breathing  and  a 
thorough  ventilation  of  the  lungs  promote  the  more  rapid  elimination 
of  the  anesthetic. 

Briining  states  that  a  patient  with  rosy  lips  and  a  pink  appearance 
might    suddenly   become   asphyxiated,    as    saturation    with    chloroform 

^  Briining :     Loc.  cit. 


84 


ANESTHESIA 


TABLE  5. 


The  figures  in  the  first  column  indicate  the  number  of  the  experiment;  the 
second  column,  the  number  of  minutes  required  to  kill. 


43^   Chloroform  1 


With 

Air 

1 

43^ 

2 

3 

3 

W2 

4 

7 

5 

4 

6 

4 

7 

3K 

8 

7H 

9 

9 

10 

53^ 

11 

7 

12 

10 

13 

6 

14 

9 

15 

10 

16 

W2 

17 

103^ 

18 

10 

19 

10 

20 

17 

21 

16 

22 

13 

23 

16 

24 

11 

25 

12 

26 

12 

2323/^  total; 
?.94  average. 


With 

Oxygen 

1 

26 

2 

5 

3 

10 

4 

5^ 

5 

30 

6 

40 

7 

28 

8 

13 

9 

5 

10 

8 

11 

15 

12 

17 

13 

30 

14 

30 

15 

13 

16 

18 

17 

14 

18 

30 

19 

163^ 

20 

37 

21 

28M 

22 

33 

23 

8 

24 

103^ 

25 

10 

26 

103^ 

27 

18 

28 

7 

29 

183^ 

30 

413^ 

31 

13 

32 

26 

33 

73^ 

34 

90 

35 

14 

36 

26 

37 

23 

38 

331^ 

809K  total; 

21.3  average 

GENERAL    PSYCHOLOGY    OF    INHALATION    ANESTHESIA 


85 


1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 


With 
Air 

15                          Ether 

18       '.'.'.'.'.'. " 

27       " 

15       " 

33 " 

16       " 

18       " 

21       " 

16       " 

9       " 

18M  " 

28M  " 


235  total; 
19  average. 

With 
Air 


Mixed  Chloroform  and  Ether  (1 :2) 


15 
30 

lOM 

15 

17 


6    30 


With 
Oxygen 

1  25 

2  29K 

3  33J^ 

4  34 

5  27 

6  40 

7  QVA 


250H  total; 
35  average. 


With 
Oxygen 


40 
16 
70 
37 

42 
22 
28^ 


117H  total; 
19  average. 

With 
Air 
3^     21  Anesthol 

2  26   ■.'.'. " 

3  10   " 


57  total; 
19  average. 


2551^  total; 
36  average. 

With 
Oxygen 

1  38 

2  14H 

3  74 

126  total; 
42  average. 


"With  Summary  With 

Air  .  0^>f  ^ 

9       Chloroform 1     21 

19       Chloroform  and  Ether   2     35 

Ether    3     35 


12 
19 


Anesthol  ^    42 


86  ANESTHESIA 

would  not  change  the  color  of  the  blood.  He  claims  that  more  oxygen  is 
set  free  in  the  plasma  of  the  blood,  and  that  the  color  depends  only  upon 
its  richness  in  oxygen  and  not  upon  its  carbon  dioxid.  Znntz  ^  holds 
that  aniinals  die  as  soon  under  oxygen-chloroform  as  under  air-chloro- 
form. In  chloroform  poisoning,  according  to  Briining,  the  first  thing  to 
do  is  to  reduce  the  concentration  of  poison  in  the  blood  and  to  eliminate 
it  from  the  body.  To  do  this,  the  circulation  must  be  maintained  so  that 
the  hypersaturated  blood  may  go  through  the  lungs  and  be  purified. 
This  is  best  accomplished  by  radical,  artificial  breathing,  thus  securing 
a  thorough  expansion  of  the  lungs.  In  this  way,  so  much  oxygen  is 
introduced  into  the  lungs  that  the  inhalation  of  concentrated  oxygen  is 
unnecessary.  Vidal  ^  asserts  that  in  primary  disturbances  of  the  respira- 
tion only  artificial  breathing  is  necessary,  as,  owing  to  the  blood  becom- 
ing rich  in  oxygen,  eupnea,  which  delays  the  excretion  of  chloroform, 
occurs. 

In  treating  accidents  in  narcosis  a  suggestion  is  made  that  oxygen 
might  exercise  a  directly  injurious  chemical  action  on  the  body  cells. 
Briining  quotes  Paul  Bert  as  stating  that  animals  die  when  exposed 
to  a  hyper-pressure  of  3-4  atmospheres  of  pure  oxygen.  As  animals,  on 
inhalation  of  ordinary  air,  died  only  on  a  hyper-pressure  of  15  to  20 
atmospheres,  he  thought  the  danger  lay  not  in  the  pressure,  but  in  the 
oxygen. 

Briining  makes  the  peculiar  statement  that,  from  his  experimenta- 
tion, the  administration  of  oxygen  after  the  narcosis  only  delays  the 
awakening,  inasmuch  as  it  never  hastens  the  elimination  of  chloroform. 
Furthermore,  in  his  ojDinion,  it  is  no  antidote  to  chloroform  in  narcosis 
accidents.  Deep,  free  breathing  is  always  sufficient  to  eliminate  the 
chloroform  from  the  system. 

The  difference  in  the  results  of  Briining's  experiments  and  those  of 
Gwathmey  can  be  explained  only  by  the  employment  of  an  entirely  dif- 
ferent technique  and  difi:erent  apparatus  under  different  conditions  of 
climate.  In  Gwathmey's  experiments,  results  were  obtained  by  elim- 
inating as  far  as  possible  every  factor  that  might  tend  to  confuse. 
Eebreathing,  as  advocated  by  Gatch,  was  used  constantly,  both  with 
oxygen  and  compressed  air.  There  is  not  the  slightest  question  but  that, 
under  proper  conditions,  oxygen,  in  a  very  great  measure,  prevents 
poisoning,  especially  in  chloroform  or  ether  narcosis. 

Miiller's  ^  experimental  findings  are  divided  into  three  groups, 
namely  chloroform-oxygen  narcosis;  ether-oxygen  narcosis;  and  com- 
bined   narcosis,    the    latter    being    subdivided    according    to    sequence, 

^Zuntz:     Berl.  Tclin.  Woch.,  1901,  No.  20. 
=  Vidal:     Zentr.  Cliir.,  1911,  No.  11. 

^  Miiller,  B. :  "  Ueber  den  Einfluss  der  Gange  mischnarkosen  auf  die  innereii 
Organe,"  Arch.  f.  Min.  Chir.,  1905,  71,  420. 


GENERAL  PHYSIOLOGY  OF  INHALATION  ANESTHESIA      87 

namely,  chloroform-ether-oxygcn  narcosis  and  ether-chloroi'orm-oxygen 
narcosis. 

Chloroform-oxygen  narcosis  diminishes  the  blood  pressure,  which 
drops  constantly  from  the  beginning  of  tolerance  to  the  end,  rising  again 
when  the  patient  awakens.  The  diminution  of  the  blood  pressure  is 
considerably  less  in  chloroform-oxygen  narcosis  than  in  simple  chloro- 
form narcosis.  The  height  of  the  blood  pressure  never  drops  so  low 
below  the  normal  blood  pressure  as  in  simple  chloroform  narcosis,  and 
the  course  of  the  oxygen-mixture  narcosis  is  of  uniform  appearance.  But 
remissions  are  not  altogether  absent,  and  the  chloroform  effect  can  there- 
fore not  be  entirely  overcome.  The  number  of  respirations  undergoes  a 
greater  diminution  with  chloroform  alone  than  with  the  oxygen-mixture 
narcosis,  in  which  it  approximates  the  normal  standard. 

Concerning  the  effect  of  the  oxygen  narcosis  upon  the  internal 
organs,  the  advantage  of  the  addition  of  oxygen  to  chloroform  consists 
in  the  removal  of  the  carbon  dioxid  and  in  its  substitution  by  oxygen, 
which  induces  a  greater  power  of  resistance  on  the  part  of  the  individual 
cells.  The  fatty  changes  of  the  cells,  as  well  as  the  effect  upon  the  heart, 
are  not  so  severe  in  mixed  as  in  simple  chloroform  narcosis.  The  mixed 
narcosis  also  involves  a  considerable  saving  of  chloroform. 

In  the  oxygen-ether  narcosis  no  depressive  effect  upon  the  blood 
pressure  was  demonstrable.  The  level  of  the  blood  pressure  was  always 
above  normal,  so  that  the  blood  pressure  was  invariably  increased,  exactly 
the  opposite  to  chloroform-oxygen  narcosis.  Ether-oxygen  acts  upon 
the  internal  organs  in  an  analogous  fashion  to  ether,  but  the  changes  are 
less  considerable,  especially  the  salivation  and  fatty  metamorphosis. 
The  difference  is  due  to  similar  factors  to  those  in  chloroform-oxygen 
inhalation,  namely,  the  lessened  consumption  of  ether,  the  supply  of 
oxygen,  and  the  prevention  of  carbon  dioxid  intoxication.  Ether-oxygen 
narcosis  possesses  less  narcotic  power  as  compared  to  simple  ether 
narcosis,  especially  in  resistant  individuals,  habitual  users  of  al- 
cohol, etc. 

Combined  oxygen  inhalation,  with  ether  and  chloroform,  is  utilized 
for  the  avoidance  of  the  disadvantages  of  these  two  methods  of  narcosis; 
it  diminishes  the  toxic  effects  of  ether  as  well  as  of  chloroform,  but 
requires  accurate  dosage,  careful  observation  of  the  patient,  and  a  knowl- 
edge of  the  indications  and  contraindications  for  the  individual  anes- 
thetic agents.  The  effects  of  ether,  for  example,  are  merely  diminished, 
but  still  present,  so  that  certain  dangers  are  involved  in  the  narcosis  if 
the  patient  is  predisposed.  Therefore,  definite  indications  must  always 
be  present  for  this  narcosis,  for  there  are  patients  who  are  predisposed  to 
a  toxic  effect  of  ether  and  unable  to  tolerate  this  narcosis.  Ether-oxygen 
narcosis  furthermore  possesses  less  narcotic  power  than  simple  ether  nar- 
cosis, and  this  is  especially  important  in  resistant  individuals,  such  as 


88  ANESTHESIA 

neurasthenics  and  habitual  users  of  alcohol,  who  in  many  cases  cannot  be 
brought  under  the  influence  of  ether-oxygen  narcosis.  A  reduced  nar- 
cotic power  is  also  frequently  noted  in  chloroform-oxygen  narcosis,  so 
that  it  is  difficult  or  impossible  to  narcotize  alcoholic  individuals.  In 
order  to  avoid  the  disadvantages  of  chloroform-oxygen  narcosis  as  well 
as  of  ether-oxygen  narcosis,  a  combination  of  the  two  narcoses  has  been 
created  in  the  form  of  combined  oxygen  narcosis,  which  is  subdivided 
into  chloroform-ether-oxygen  narcosis  and  ether-chloroform-oxygen  nar- 
cosis. By  means  of  these  combined  narcoses  the  dangers  and  disadvan- 
tages of  inhalation  narcosis  are  much  reduced.  The  favorable  effects  of 
these  narcoses  are  due  to  diminution  of  the  toxic  action  of  ether  as  well 
as  chloroform. 

Miiller  ^  investigated  the  fatty  changes  of  the  vital  parenchymatous 
internal  organs  in  animals  after  simple  and  mixed  narcoses.  It  was 
found  that  any  narcosis  gives  rise  to  a  more  or  less  well-marked  incipient 
fatty  metamorphosis  in  the  internal  organs.  The  change  in  the  kidney 
is  frequently  not  marked  enough  for  albuminuria  to  appear,  but  some 
alteration  of  the  epithelia  is  present  after  all  narcoses.  This  incipient 
fatty  metamorphosis,  which  does  not  attack  all  cells  at  once,  promptly 
subsides  again.  An  existing  fatty  metamorphosis,  such  as  is  caused,  for 
example,  by  a  preceding  narcosis,  becomes  seriously  aggravated  by  a  re- 
peated inhalation  of  narcotic  agents.  It  makes  no  difference  what  anes- 
thetic is  used;  chloroform,  chloral  hydrate,  and  ethyl  bromid  have  the 
most  energetic  action  in  this  respect;  the  last  named  agent  being  alto- 
gether useless  for  prolonged  narcosis.  Ether  acts  in  a  general  way  less 
strongly  upon  the  heart  and  brain,  but,  after  several  narcoses  with  ether, 
fatty  changes  are  likewise  found  in  these  organs.  Each  prolonged  ether 
narcosis  is  followed  by  small  pneumonic  foci  in  the  lungs,  with  mucus  in 
the  alveoli,  collection  of  blood  corpuscles  in  the  alveoli,  and  round  cell  in- 
filtration in  the  surrounding  tissue.  These  lung  changes  are  of  slight 
degree  with  chloroform.  On  the  other  hand,  the  liver  and  the  kidney 
are  affected  less  by  ether  than  by  chloroform.  In  a  general  way,  there 
is  a  certain  uniformity  about  the  injurious  effects  of  the  various  nar- 
.cotics,  except  graded  differences  in  the  intensity  of  the  action.  Mixtures 
of  chloroform  and  ether  were  found  to  be  by  no  means  better  anesthetics, 
but  rather  possessed  worse  properties.  The  experiments  showed  that  any 
mixture  which  contained  chloroform  did  not  act  very  differently  from 
a  pure  chloroform  narcosis.  Mixed  ether  narcoses  were  followed,  like  the 
pure  ether  narcoses,  by  pneumonias  of  the  above-described  type. 

The  practical  application  of  these  findings  consists  in  the  best  possi- 
ble abbreviation  of  the  narcosis;    the   avoidance   of  repeated  narcosis 

^Miiller,  B.:  "Ueber  Fettmetamorphose  in  den  inneren  parenchymatosen 
lebenswichtigen  Organen  nach  einfachen  und  Misch-Narkosen. "  Arch.  f.  Min. 
Chir.,  1905,  75,  896. 


Fig.  14. — Oxygen  Passing  through  Rubber  Ccil  Immersed  in  Hot  Water  (Service 

of  Dr.  Bainbridge) . 


Fig.    15.  —Intra-abdominal    Administration    of    Oxygen   in    Case    of    Intestinal 

Adhesions. 


90 


ANESTHESIA 


within  three  to  six  days;  and  the  examination  of  the  organs  before  each 
narcosis,  as  to  a  preexisting  fatty  metamorphosis.  Certain  aifections 
are  a  strict  contra-indication  against  any  narcosis,  especially  fatty  meta- 
morphosis in  the  heart,  kidneys,  and  liver. 

The  Influence  upon  Anesthesia  of  Oxygen  Intra-abdominally  Ad- 
ministered.— It  is  not  proposed  in  the  present  volume  to  consider  surgical 

subjects  such  as  may  re- 
late to  or  modify  the  ad- 
ministration of  a  n  e  s  - 
thetics.  However,  it  is  of 
importance  to  note  the 
effect  upon  anesthesia  of 
oxygen  administered  in- 
tra-abdominally, accord- 
ing to  the  method  of  Bain- 
bridge,^  who  instituted,  for 
purposes  not  connected 
with  anesthesia,  a  series 
of  animal  experiments 
with  oxygen  and  air, 
which  verified,  in  a  re- 
markable manner,  our  ex- 
periments with  oxygen 
and  the  different  anes- 
thetics. 

In  a  series  of  experi- 
ments to  determine  the 
difference  between  oxygen 
and  air,  oxygen  was  intro- 
duced into  the  abdomen 
following  the  technique 
as  described  upon  human  beings.  It  was  found  that  oxygen  was 
completely  absorbed  in  alk  cases  left  undisturbed  for  seventy-two  hours. 
There  was  a  slight  increase  in  pulse  rate  and  respiration,  also  a  slight 
rise  in  blood  pressure.  The  effect  upon  the  degree  of  anesthesia 
was  marked,  the  animal  showing  a  tendency  to  recover  almost  immedi- 
ately from  the  influence  of  the  anesthetic.  In  cases  where  the  anesthesia 
was  profound,  reflexes  quickly  became  active.  Animals  into  which  the 
oxygen  had  been  introduced  were  able  to  stand  up  from  two  to  ten 
minutes  after  the  discontinuance  of  the  anesthetic.  All  reactions  were 
more  prompt  when  warmed  .oxygen  was  used  instead  of  oxj^gen  at 
normal  temperature.     The  dark  blood  was  changed  to  scarlet.     In  no 

^  Bainbridge,  W.  S. :     Annals  of  Surgery,  March,  1909 ;  N.  Y.  J.  Med.,  June, 
1908;  N.  Y.  Med.  J.,  Apr.,  1909. 


FiG.^  16. — Suturing  op  the  Peritoneum.  Continu- 
ous stitch  to  inserted  tube;  purse-string  stitch 
(1)  encircling  tube. 


GENERAL  PHYSIOLOGY  OE  INHALATION  ANESTHESIA      91 

case  was  there  macroscopic  evidence  that  oxygen  was  an  irritant  to  the 
peritoneum  or  any  of  the  abdominal  viscera.  It  was  also  found  that 
oxygen  stimulated  intestinal  peristalsis. 

When  air  was  introduced  instead  of  oxygen,  the  pulse,  respiration, 
and  blood  pressure  were  particularly  influenced,  and  the  degree  of  anes- 


FiG.  17. — Aponeurosis  United  with  Interrupted  Sutures,  the  Muscle  Having  Been 
Previously  Sutured.  (1)  Untied  ends  of  peritoneal  purse-string;  (2)  Untied  suture 
through  aponeurosis,  passing  halfway  around  tube. 


thesia  was  not  affected.  The  time  required  for  recovery  after  the  anes- 
thetic agent  had  been  discontinued  was  from  fifteen  to  twenty-five 
minutes. 

In  the  abdominal  administration  of  oxygen  Bainbridge  employs  a 
gas  containing  94-97  per  cent  oxygen.  The  gas  is  warmed  to  a  tem- 
perature of  90°-100°  F.,  by  passing  it  through  a  rubber  tube  from  the 
tank  in  which  it  is  compressed  into  a  wash  bottle  filled  with  hot  water. 
From  this  bottle  the  partially  warmed  gas  passes  through  the  exit  tube. 
This  long  exit  tube  is  again  connected  to  a  piece  of  glass  tubing,  and 
to  this,  in  turn,  is  attached  a  piece  of  sterile  rubber  tube,  through 
which  the  gas  is  introduced  into  the  abdominal  cavity.      (Figs  14  and 

15.) 

Animal  experiments  and  clinical  experience  in  a  large  number  of 


92 


ANESTHESIA 


cases  have  proven  that  oxygen  can  be  safely  administered  intra-abdom- 
inally,  that  it  lessens  shock,  controls  hemorrhage  from  small  vessels, 
lessens  the  degree  of  cyanosis,  nausea,  and  vomiting,  prevents  the  for- 
mation of  adhesions,  and  stimulates  to  such  a  degree  that  more  anes- 
thetic is  necessary  in  order  to  keep  the  patient  anesthetized  until  the 
completion  of  the  operation.  The  technique  of  closing  the  wound 
and  withdrawing  the  rubber  tube,  so  as  to  prevent  the  leakage  of 
oxygen,  either  into  the  tissues  or  into  the  surrounding  atmosphere, 
is  shown  in  Figures  16,  17,  18,  and  19. 

Preceding  the  Administration 
with  Oil  of  Bitter  Orange  Peel. — 
A  procedure  which  exerts  a  striking 
influence  upon  the  course  of  anes- 
thesia is  the  preliminary  adminis- 
tration by  inhalation  of  oil  of  orange 
(25  per  cent  oil  of  bitter  orange 
peel,  U.  S.  P.,  with  75  per  cent  of 
alcohol,  U.  S.  P.). 

Gwathmey,^  who  first  employed 
this  method,  had  long  been  in  the 
habit  of  preceding  the  anesthesia  by 
the  administration  of  a  one  per  cent 
vapor  of  cologne  or  whiskey,  the 
agent  being  placed  in  one  of  the 
bottles  of  his  three-bottle  vapor  ap- 
paratus (see  illustration,  p.  225). 
Later  he  adopted  oil  of  bergamot  or 
terpineol  ^  for  the  purpose  of  mask- 
ing the  odor  of  ether  vapor.  (See 
Chapter  VIII.) 

Finding  the  induction  period  of 
anesthesia  thus  deprived  of  its  ter- 
rors for  many  patients,  particularly 
for  nervous  women  and  frightened 
children,  the  subject  lapsing  quietly  into  unconsciousness  when  the  anes- 
thetic vapor  was  turned  on,  a  search  was  instituted  for  a  substance  with 
a  more  penetrating  yet  none  the  less  agreeable  odor,  which  could  be 
vaporized  and  utilized  as  a  preliminary  to  ether  or  other  inhalation 
anesthetic  agent. 

With  this  object  in  view,  the  authors  experimented  with  a  number  of 

^Gwathmey:     "The  Vapor  Method  of  Anesthesia,"  Med.  Bee,  Oct.  14,  1905. 

^Gwathmey:  Terpineol  ("lilaeine")  serves  to  mask  the  odor  of  ether  vapor, 
and  is  a  respiratory  antiseptic,  but,  like  oil  of  sweet  orange,  is  less  satisfactory 
than  oil  of  bitter  orange  peel,  because  of  its  very  sweet  odor. 


Fig.  18. — Superficial  Fascia  United. 
(1)  Untied  peritoneal  purse-string;  (2) 
Untied  aponeurosis  suture. 


GENERAL  PHYSIOLOGY  OF  INHALATION  ANESTHESIA     93 


odoriferous  substances.^  From  the  table  (page  94),  by  Passy,^  quoted 
by  Tigerstedt,^  and  rearranged  here  in  the  sequence  of  penetrating 
power,  it  will  be  seen  that  other  odorifer- 
ous substances  exceed  oil  of  orange  in 
penetrative  power.  To  these,  however, 
some  patients  might  find  objection, 
whereas  to  the  delightful  odor  of  oil  of 
bitter  orange  peel  it  is  hardly  likely  that 
anyone  would  object.* 

The  table  shows  how  many  milli- 
grams of  odorous  substances,  respective- 
ly, must  be  contained  in  one  liter  of  air 
in  order  to  produce  a  barely  perceptible 
olfactory  sensation.  The  list  illustrates 
the  functional  capacity  of  the  human  ol- 
factory organ  in  regard  to  quantity. 

Zwaademaker,^  using  the  olfactom- 
eter, noticed  that  in  the  case  of  certain 
odoriferous  substances  the  threshold,  or 
very  first  beginning,  of  perception  takes 
on  a  high  value,  under  increasing  con- 
centration, after  a  certain  optimum  has 
been  reached. 

With  the  above  facts  in  mind, 
Gwathmey  employed  oil  of  bitter  orange 
peel  in  alcoholic  solution,  first  using  it 
by  the  drop  method  with  ether.  He 
found  that  in  this  way  the  odor  of  ether 
was  completely  masked,  not  only  for  the 
patient   but   for   the    occupants   of   the 

operating  room  as  well.  The  patient  passed  into  the  stage  of  surgical 
anesthesia  as  one  dropping  into  a  profound  sleep.  There  was  no  stage 
of  excitement,  the  nausea  and  vomiting  being  materially  reduced.     The 


Fig.  19. — Tube  Withdrawn;  Peri- 
toneal Purse-string  Tied; 
Knot  Beneath  Aponeurosis. 
(3)  Aponeurosis  suture.  Figure 
illustrates  practicability  of  plac- 
ing skin-stitches  while  tube  re- 
mains in  the  abdomen. 


^Nussbaum  {Rundschau,  1888,  759)  found  that  the  odor  of  chloroform  vapor 
might  be  masked  by  means  of  oil  of  cloves.  In  the  experiments  of  the  authors, 
the  masking  agents  tried  (terpineol,  oil  of  bergamot,  oil  of  patchouli,  oil  of 
lemon,  orange,  etc.)  were  superimposed  upon  water  at  37°  C,  and  the  anesthetic 
vapor  was  then  passed  through. 

-  Passy :  ' '  Forme  periodique  du  pouvoir  odorant  dans  la  serie  grasse, ' '  Compt. 
rend.  Acad.  d.  Sciences,  1893,  116,  1007. 

"Tigerstedt:     "Lehrbuch  der  Physiologie  des  Menschen,"  1902,  f,  132. 

*  Eulimen,  a  pure  limonene  (density,  0.850  at  15°  C. ;  boiling  point,  175°  C), 
prepared  according  to  a  patented  process  (D.  R.-P.  204,  163),  has  been  proposed 
as  an  addition  to  narcotic  mixtures  ("Riedel's  Mentor,"  1911,  152). 

°  Zwaademaker,  H. :      "  Die  Physiologie  des  Geruches, ' '  Leipsic,  1895. 


94  ANESTHESIA 

TABLE  6. 

Milligrams  per  liter  of  air 

Mint  leaves  {Folia  Menthce) 0 .  0000005  —  0 .  00001 

Essence  of  Wintergreen 0 .  000005    —  0 .  0004 

Orange  essence 0.00005      —0.001 

Ether 0.0005       —0.004 

Camphor 0 .  005  — 

Natural  musk 0.01  —0.1 

entire  administration  progressed  smoothly,  and  the  patient  recovered 
from  the  anesthetic  with  none  of  the  after-effects  so  frequently  noted 
with  ether.^ 

Woolsey,  of  Brooklyn,  developed  and  perfected  the  method  of  employ- 
ing the  oil  of  orange-ether  sequence  by  the  closed  method  with  the  three- 
bottle  vapor  inhaler.  He  has  a  record  of  over  200  cases.  He  uses  it 
wherever  the  nitrous  oxid-ether  sequence  is  indicated  and  prefers  it  to 
the  latter  method.  It  is  unquestionably  of  inestimable  value,  especially 
where  the  transportation  back  and  forth  of  the  nitrous  oxid  cylinders 
is  a  matter  of  consideration.     The  technique  is  as  follows :  ^ 

The  water  bottle  is  filled  with  the  usual  amount  of  water,  namely,  3^ 
to  3  ounces.  A  solution  of  oil  of  orange,  of  the  composition  described, 
in  one-  to  two-dram  quantity,  is  placed  in  the  water.  Ether  (four  to  six 
drams)  is  placed  in  the  chloroform  bottle,  which  receptacle  is  sur- 
rounded by  lukewarm  water.     The  usual  quantity  of  ether   (4  ounces) 

*  French  has  used  the  drop  method  of  oil  of  orange-ether  in  over  50  cases ;  he 
states:  "One  of  the  most  important  and  valuable  recent  contributions  to  anes- 
thesia methods  is  the  ability  to  omit,  or  bridge,  the  second  stage,  or  stage  of 
excitement,  and,  judging  by  the  results  obtained,  we  are  deeply  impressed  with 
the  desirability  of  attaining  narcosis  without  struggle.  This  can,  without  doubt, 
be  accomplished,  in  the  period  of  induction,  with  nitrous  oxid;  but,  in  our 
judgment,  it  can  be  done  with  greater  ease  and  certainty  with  the  essence  of 
orange.  It  unquestionably  requires  a  large  experience  with  the  administration 
of  nitrous  oxid  to  enable  one  to  dovetail  it  so  accurately  with  the  ether  which 
follows  that  the  stage  of  excitement  will  be  eliminated.  It  can,  however,  be  done, 
and  when  done  successfully,  if  all  other  things  are  equal,  we  can  safely  predict 
the  best  prospect  for  the  operation  and  the  best  condition  during  recovery.  The. 
remarkable  effects  of  the  oil  of  orange  as  a  preliminary  to  ether  have  been  dem- 
onstrated in  our  clinic,  and  have  proved  to  our  satisfaction  that,  with  it,  the  ad- 
ministration of  ether  is  made  far  less  disagreeable  and  that  it  greatly  assists  in 
the  reduction  of  shock  by  bridging  the  stage  of  excitement.  We  have  used  it 
repeatedly  with  perfect  success,  the  patients  sinking  into  complete  anesthesia  as 
a  child  falls  to  sleep.  Our  observations  thus  far  have  brought  the  belief  that  an 
anesthesia  conducted  in  this  way  is  a  contributive  factor  in  reducing  hemorrhage, 
also  in  reducing  the  quantity  of  the  anesthetic  and  in  shortening  and  modify- 
ing the  anesthetic  after-effects."  French,  Thomas  E. :  "Nitrous  Oxid,  Es- 
sence of  Orange,  Ether,  and  Sequestration  in  General  Anesthesia,"  N.  Y.  Med. 
J.,  May  24,  1913. 

*See  also  "Vapor  Method  of  Anesthesia." 


GENERAL  PHYSIOLOGY  OF  INHALATION  ANESTHESIA     95 

is  placed  in  the  ether  bottle.  The  index  is  turned  to  "Air/'  and  the 
bag  is  filled  with  the  air  pumped  through  the  water  bottle,  which  con- 
tains the  oil  of  orange.  The  mask  is  placed  upon  the  patient's  face,  and 
the  patient  breathes  back  and  forth  in  the  bag.  The  air  is  pumped 
vigorously  so  as  to  keep  the  bag  two-thirds  full  at  all  times.  The  index 
is  turned  gradually  toward  "Chloroform,"  the  receptacle  in  which  the 
four  to  six  drams  of  ether  are  placed.  The  patient  is  now  getting  a  very 
small  amount  of  ether,  which  is  apparently  imperceptible.  The  index  is 
gradually  turned  to  full  "Chloroform,"  the  patient  getting  more  and 
more  of  the  mild  attenuated  ether  vapor.  If,  at  this  time,  the  patient 
coughs,  sneezes,  or  swallows,  or  shows  in  any  way  that  he  perceives  the 
ether,  the  index  is  immediately  turned  back  to  "Air."  The  same  pro- 
cedure is  repeated  until  the  index  reaches  full  "Chloroform."  When 
this  is  accomplished  the  index  is  turned  back  to  air  again  and  gradually 
turned  toward  "Ether."  The  expiratory  valve  is,  at  all  times,  only 
slightly  open.  The  bag  remains  moderately  distended,  a  slight  positive 
pressure  being  a  decided  advantage  in  some  cases,  the  expiratory  valve 
permitting  a  continuous  but  small  escape  of  air.  The  patient  will  now 
be  found  to  be  in  a  state  of  full  surgical  anesthesia,  the  average  time 
required  to  reach  this  stage  being  four  and  one-half  minutes.  Anes- 
thesia is  maintained  with  the  index  turned  for  one-eighth  to  one-quarter 
of  an  inch  from  air,  but  between  "air"  and  "ether,"  constant  pumping 
being  continued  at  all  times.  The  breathing,  as  a  rule,  is  quiet  and 
regular,  approximating  the  breathing  in  chloroform  anesthesia  more 
nearly  than  that  usually  seen  with  ether.  The  lid  reflex  is  absent,  the 
eyeballs  are  rolling,  but  the  patient  is  sufficiently  relaxed  for  all  surgical 
operations.  The  usual  amount  of  ether  used  with  this  method  is  two  or 
three  ounces  for  the  first  hour  and  one  ounce  for  the  second.  The  after- 
effects are  usually  conspicuous  by  their  absence.  The  patient  goes  under 
in  practically  the  same  way  as  with  a  good  nitrous  oxid-ether  sequence. 
There  is  no  struggling  or  other  indication  of  the  seco7id  stage.  The  pulse 
is  normal,  the  color  reflex  good,  and  there  is  no  disturbing  mucous  rale. 
The  physiological  basis  for  the  beneficial  effect  of  oil  of  orange 
in  the  administration  of  inhalation  anesthetics  may  be  found  in  the  pre- 
vention of  reflex  stimulation,  by  the  anesthetic  agent,  of  certain  sensory 
nerves.  Dastre  ^  attributed  early  syncope  to  reflex  stimulation  of  the 
pneumogastric  and  trigeminal  nerves,  particularly  the  sensory  branches 
supplying  the  nasal  mucous  membrane  and  the  larynx.  Embley  ^  has 
also  emphasized  the  part  played  by  the  increased  excitability  of  the 
vagus  mechanism,  particularly  during  the  early  part  of  the  administra- 
tion. In  his  inhalation  experiments  Embley  found  that  failure  of 
respiration  is  mainly  due  to  fall  in  blood  pressure.     With  good  blood 

^"Les  anesthetiques, "  Paris,  1901,  104-109. 
==  Embley:     Brit.  Med.  J.,  April  5,  12,  19,  1902. 


96  ANESTHESIA 

pressure,  failure  of  respiration  (his  experiments  concerned  chloroform) 
is  practically  impossible.  Eestoration  of  respiration  is  dependent  upon 
restoration  of  blood  pressure.  The  chances  of  dangerous  vagus  inhibi- 
tion aTe  greatly  increased  by  imperfect  respiration. 

From  these  findings  it  would  seem  fair  to  assume  that  any  factor 
which  prevents  undue  reflex  inhibition  of  the  nervous  mechanism  of 
respiration  and  which,  by  its  stimulation  of  the  respiratory  center,  pre- 
vents fall  in  blood  pressure,  will  have  a  beneficial  influence  upon  the 
course  of  the  anesthesia.  The  oil  of  orange  seems  to  exert  this  bene- 
ficial influence  by  dulling  the  sense  of  smell  to  such  an  extent  that  the 
odor  of  the  anesthetic  agent  is  not  noticeable  during  the  administration. 
It  has  been  determined  by  our  laboratory  experiments  upon  guinea-pigs 
that  the  oil  of  orange  exhibits  no  pronounced  anesthetic  effect  upon  these 
animals.  The  exact  nature  of  its  physiological  action  is,  therefore,  yet 
to  be  determined. 

The  smoothness  of  the  anesthesia  seems  to  the  authors  to  be  depend- 
ent upon  the  power  of  oil  of  orange  to  obtund  the  olfactory  nerve  to  such 
an  extent  that  the  odor  of  the  ether  vapor  is  not  noticeablfe.  This  view 
has  not  been  verified  by  laboratory  experimentation,  however. 

Concerning  this  "Mystery  of  Ether  Anesthesia,"  ^  as  this  action  of 
oil  of  orange  has  been  called,  the  following  comment  is  made: 

"We  are  confronted  here  with  a  problem  that  has  so  far  eluded  solu- 
tion. The  problem  of  noci  and  anoci  associations  finds  instant  solution, 
at  least  as  far  as  its  practical  aspect  is  concerned.  With  a  few  drops  of 
oil  of  orange  (in  alcoholic  solution)  we  accomplish  all  that  formerly 
demanded  much  preliminary  psychic  care,  gas-oxygen  inhalations,  and 
injections  of  novocain,  and  quinin  and  urea  hydrochlorid  before  and 
after  anesthesia.  Are  pleasant  odors  narcotic  to  the  olfactory  nerve? 
Is  that  some  explanation  of  their  widespread  and  age-long  use?  Certain 
unpleasant  odors  are  undoubtedly  terrifying  to  animals,  those  of  their 
enemies,  for  example.  If  pleasant  odors  are  indeed  sedative  to  the  olfac- 
tory nerve,  does  that  suffice  to  explain  their  extraordinary  influence,  at 
least  when  followed  by  ether,  over  the  entire  nervous  system  ?  Is  there  ■ 
merely  an  association  of  ideas?  The  smell  of  ether  is  associated  with 
the  surgical  knife  in  the  minds  of  adults,  and  is  terrifying  to  children 
from  its  irritating  qualities.  Perhaps  the  very  familiarity  and  the  harm- 
lessness  associated  with  the  odors  of  flowers  and  fruit  are  sufficient  to 
suggest  powerfully  to  the  subject  that  what  he  is  about  to  undergo  can- 
not be  dangerous,  or  even  unfamiliar.'^ 

TTtilizing  Carbon  Dioxid. — The  physiological  importance  of  the  car- 
bon dioxid  content  of  the  blood  has  only  recently  come  to  be  fully  recog- 
nized. Of  still  more  recent  origin  is  the  demonstration  of  its  relation 
to  the  administration  of  inhalation  anesthetics. 

^"A  Mystery  of  Ether  Anesthesia,"  Editorial,  N.  Y.  Med.  J.,  Sept.  14,  1912. 


GENERAL  PHYSIOLOGY  OF  INHALATION  ANESTHESIA      97 

Extensive  investigations  by  physiologists  in  America  and  Europe 
have  established  the  fact  that  carbon  dioxid  is  not  merely  a  waste- 
product^  but  performs  a  distinct  role  as  a  "harmone,"  or  chemical-regu- 
lator of  various  functions.  The  carbon  dioxid  content  of  the  blood, 
according  to  Henderson/  exercises  regulative  influences  upon  the  heart- 
rate,  upon  the  vascular  tonus,  upon  the  peristalsis  of  the  alimentary 
canal,  upon  the  mental  condition,  and  upon  a  number  of  other  functions 
of  the  body.  From  the  data  presented  by  him  it  appears  that  even  a 
slight  reduction  in  the  carbon  dioxid  content  of  the  arterial  blood 
causes  a  marked  quickening  of  the  heart-rate.  "Further  reduction,"  he 
says,  "induces  an  extreme  tachycardia,  complete  cessation  of  peristalsis, 
failure  of  many  reflexes,  and  coma.  If  an  extreme  reduction  of  the  CO, 
content  of  the  blood  is  effected  very  rapidly,  the  heart  comes  into  a  state 
bordering  on  tetanus.  This  cardiac  tetanus  practically  abolishes  the 
pumping  action  of  the  heart.     Arterial  pressure  falls  and  death  results. 

"If  the  reduction  in  the  arterial  CO2  is  less  extreme,  but  is  main- 
tained for  a  considerable  time  (an  hour  or  more,  according  to  the  extent 
of  the  reduction),  so  that  the  tension  of  COo  in  the  venous  blood  and  in 
the  tissues  is  reduced,  symptoms  and  conditions  result  which  are  sim- 
ilar, in  many  respects,  to  those  occurring  in  mountain  sickness  and  are 
apparently  identical  with  those  of  surgical  shock.  Arterial  pressure  falls 
to  a  very  low  level,  and, 'if  the  condition  is  continued,  the  circulation 
fails.  The  fall  is  not  due  merely  to  tachycardia,  for  the  heart-rate  in 
the  later  stages  is  not  always  extremely  rapid,  but  is  caused  by  a  loss  of 
tonus  in  the  peripheral  veins  and  capillaries,  and  by  the  consequent  stag- 
nation of  the  blood  in  these  vessels.  The  mental  condition  of  the  subject 
is  comatose.  The  reflexes  are  greatly  reduced  in  responsiveness.  Vigor- 
ous stimulation  of  afferent  nerves  causes  no  rise  of  arterial  pressure. 
The  condition  of  the  nervous  system  and  the  stage  of  excitement  through 
which  it  develops  are  not  due  primarily  to  the  fall -of  arterial  pressure. 
They  precede  the  fall.  Although  the  coma  is,  of  course,  intensified  by  a 
low  pressure,  it  may  occur  to  a  considerable  extent  coincidently  with  the 
high  pressure  of  the  earlier  stages. 

"The  respiration,  when  the  subject  is  left  to  breathe  naturally,  be- 
comes very  shallow.  It  is  liable  to  pass  into  apnea.  This  condition  is 
the  direct  effect  of  the  reduced  CO,  tension  in  the  respiratory  center." 

The  reduction  of  carbon  dioxid  leading  to  the  conditions  described 
can  be  effected  by  various  means  detailed  by  Henderson,  among  which 
may  be  mentioned  as  having  a  practical  bearing  upon  anesthesia:  (1) 
artificial  respiration;  (2)  the  hyperpnea  incident  to  the  stage  of  excite- 
ment of  incomplete  anesthesia;    (3)  the  hyperpnea  produced  by  vigor- 

^  Henderson,  Yandell:  "Acapnia  and  Shock,"  Am.  J.  Physiol.,  Feb.  1, 
1908;  Feb.  1.  1909;  April' 1,  1909;  Feb.  1,  1910;  June  1,  1910;  Nov.  1,  1910; 
Aug.   1,  1911. 


98  ANESTHESIA 

ous  and  prolonged  stimulation  of  the  afferent  nerves;  (4)  exposure  of 
the  abdominal  viscera  to  the  air  so  as  to  allow  a  free  exhalation  of  carbon 
dioxid  from  the  surface  of  these  organs.  Vq,riations  in  the  oxygen  con- 
tent of  the  blood,  according  to  Henderson,  play  little  part,  if  any,  in  the 
production  of  these  conditions.  The  regulation  of  the  carbon  dioxid 
tension  of  the  air  in  the  pulmonary  alveoli,  and  the  extent  to  which 
carbon  dioxid  is  eliminated  from  the  blood  in  its  passage  through  the 
lungs,  appeared  to  him  to  be  the  most  important  factors  in  the  preven- 
tion of  shock.  In  experiments  in  which  he  had  induced  shock,  Hender- 
son found  that  restoration  of  carbon  dioxid  to  the  tissues  and  blood  (or 
rather  the  maintenance  of  a  condition  which  permits  the  tissues  rapidly 
to  restore  their  CO2)  proved  effective  in  inducing  rapid  recovery. 
"Under  all  conditions,  except  during  hyperpnea,  in  which  condition  the 
cardiac  activity  is  increased  sympathetically  with  the  respiratory  excite- 
ment, and,  to  a  certain  extent,  even  in  this  condition,  the  heart-rate  can 
be  kept  down  and  the  development  of  shock  prevented."  ^ 

It  is  important  to  note  that  in  the  absence  of  respiratory  excitement 
the  heart-rate  is  an  index  which  varies  inversely  as  the  carbon  dioxid 
content  of  the  arterial  blood.  The  investigations  which  led  Henderson  to 
make  his  extensive  experiments  and  observations,  and  his  own  work,  are 
briefly  reviewed  in  the  section  on  Shock  (see  p.  383). 

The  experiments  of  Henderson  and  the  observations  of  Mosso  ^  led 
Levi,2  in  1910,  to  consider  the  practicability  of  utilizing  mixtures  of 
carbon  dioxid  with  oxygen  for  the  purpose  of  stimulating  the  bulbar 
centers  in  surgical  cases  in  which  the  automatic  activity  of  these  centers 
is  temporarily  paralyzed  in  consequence  of  the  effects  of  chloroform  or 
ether,  or  operative  trauma,  or  of  a  combination  of  these  causes.  He  first 
experimented  on  animals.  Failure  of  respiration  was  induced  by  means 
of  the  single  or  combined  action  of  nitrites,  chloroform,  and  morphin. 
The  animals  were  then  made  to  inhale  a  mixture  of  oxygen  with  carbon 
dioxid  in  percentages  from  10  to  30.  In  every  case  he  noted  an  almost 
immediate  return  of  the  breathing  and  the  effects  of  the  inhalation  were 

^  Henderson 's  method  for  regulating  the  heart  rate  in  his  early  experiments 
'  *  depended  upon  the  manipulation  of  the  hand  bellows  with  which  artificial 
respiration  was  administered,  and  on  the  adjustment  of  the  escape  vent  in  the 
side  of  the  cannula  tied  into  the  trachea.  As  the  pulmonary  ventilation  was  in- 
creased or  diminished,  the  heart  rate  was  correspondingly  accelerated  or  retarded. ' ' 

2  Mosso:     Arch.  exp.  Path.  u.  Pharm.,  1906,  54,   285. 

s  Levi,  Ettore:  "The  Clinical  Use  of  Carbon  Dioxid  with  Oxygen,"  J.  Am. 
Med.  Assn.,  March  16,   1912. 

Also :  ' '  Nota  preventia  sulle  applicazioni  terapeutiche,  nella  pratica  chirur- 
gica  e  medica  di  mischele  li  ossigeno  e  di  anidriole  carbonica, "  Acad.  med.  fis., 
Frienze,  March  16,  1910;  "8tudi  suU'azione  fisiopatologica  dell 'anidriole  car- 
bonica, e  sulle  applicazioni  terapeutiche,  nella  pratica  chirurgica  e  medica,  di 
mescele  di  ossigeno  ed 'anidriole  carbonica,"  Bev.  Crit.  di  Clin.  Med.,  1910,  Nos. 
30  and  31. 


GENERAL  PHYSIOLOGY  OF  INHALATION  ANESTHESIA      99 

•found  to  last  for  some  time  after  the  mixture  had  been  discontinued. 

He  then  administered  these  gas  mixtures  to  patients  who  were  in  a 
state  of  partial  or  complete  coma  as  a  consequence  of  trauma  or  extensive 
and  prolonged  operation.  With  mixtures  of  from  5  to  20  per  cent  of 
carbon  dioxid  in  oxygen,  the  depth  of  breathing  and  the  regularity  of 
the  rhythm  were  notably  improved.  His  most  satisfactory  results  were 
obtained  with  a  mixture  containing  15  per  cent  of  carbon  dioxid.  In 
cases  which  exhibited  Cheyne- Stokes  respiration,  normal  breathing  was 
restored,  continuing  so  for  some  time  after  the  inhalation  of  the  gas 
mixture  ceased.  Marked  improvement  in  circulation  was  also  noted,  the 
disappearance  of  cyanosis  being  one  of  the  most  striking  features. 

In  routine  practice  Levi  employs  the  mixture  of  carbon  dioxid  and 
oxygen  as  soon  as  the  slightest  tendency  to  failure  of  respiratory  or  car- 
diac function  appears.  The  almost  invariable  result,  during  nearly  two 
years  of  experience  with  the  method  in  hundreds  of  cases,  has  been  a 
rapid  return  of  normal  heart  action  and  breathing.  The  best  results  were 
noted  where  the  condition  of  shock  had  not  progressed  too  far,  although 
striking  beneficial  results  were  obtained  even  in  the  latter  cases. 

It  is  interesting  to  note  that  Levi's  observations  with  this  method 
seemed  to  him  to  afford  an  explanation,  to  some  extent,  of  the  good 
effects  obtained  with  the  method  employed  in  connection  with  artificially 
reduced  circulation  (see  Sequestration  Method,  p.  467).  "It  seems  prob- 
able," he  says,  "that  the  remarkable  rapidity  with  which  patients  sub- 
jected to  narcosis  under  this  condition  recover  consciousness,  as  observed 
by  many  authors,  is  due  to  the  sudden  return  to  the  general  circulation 
of  a  large  amount  of  blood  rich  in  carbon  dioxid,  when  the  lower  limbs 
are  unbandaged.  Following  up  this  suggestion,  we  have  found  that  the 
use  of  a  gas  mixture  containing  from  10  per  cent  to  15  per  cent  of 
carbon  dioxid  after  the  completion  of  an  operation  is  very  effective  in 
causing  a  prompt  awakening  of  the  patient.  It  seems  also  to  tend  to 
decrease  the  post-chloroformal  vomiting.  This  is  doubtless  referable 
to  the  rapid  elimination  of  chloroform  from  the  blood  and  tissues  under 
the  influence  of  the  increased  respiration  induced  by  the  carbon  dioxid." 

Levi  does  not  give  the  technique  by  which  he  obtains  the  definite  per- 
centages of  carbon  dioxid.  Henderson  has  perfected  an  apparatus  for 
definitely  controlling  the  percentages  of  carbon  dioxid.  The  requisite 
carbon  dioxid  percentage  may  be  maintained  by  means  of  rebreathing  as 
follows :  When  too  much  carbon  dioxid  is  lost,  as  judged  by  the  symptoms 
detailed  (p.  97),  the  amount  may  be  increased  by  allowing  the  subject  to 
rebreathe  for  from  three  to  six  minutes,  according  to  requirements,  the 
anesthetic  agent  being  discontinued  meanwhile.  When  the  breathing  be- 
comes forced  and  other  signs  of  distress  appear,  suggesting  too  much  car- 
bon dioxid,  rebreathing  is  discontinued  and  the  administration  of  the  an- 
esthetic is  resumed.   Four  per  cent  has  been  found  to  be  the  limit  of  safety. 


CHAPTEE    III 

THE    USE    OF    EEBEEATHING    IN    THE    ADMINISTRATION    OF 

ANESTHETICS  i 

W.  D.  Gatch,  M.D. 

Ether:  Effect  of  Ether  Vapor  on  Eespiratory  Passages;  Compari- 
son of  Toxic  Effects  Following  Use  of  Open  and  Closed  Methods;  Ef- 
fect of  Over-Concentration  of  Ether  Vapor. 

JSTiTROUs  OxiD  Alone  and  Combined  with  Ether:  Method  of 
Administration;  Basis  of  Technique;  Practical  Advice;  Maintenance  of 
Ether  Balance;  Elimination  of  Ether  from  the  System;  Effect  of  Mor- 
phin  on  Ether  Elimination ;  Clinical  Eesults ;  Long  Operations ;  Fatali- 
ties ;  Cardiac  Cases ;  Hypercapnia ;  Acapnia ;  Ether  and  Acapnia ;  Other 
Advantages  of  Eebreathing;  Post- Anesthetic  Nausea;  Post- Anesthetic 
Abdominal  Distention;  Post- Anesthetic  Lung  Complications;  Method 
Demands  Experience. 

Chloroform  and  Ethyl  Chlorid:  Suggested  Investigations; 
Dangers;  Advantages. 

Eebreathing  in  the  administration  of  ether  and  chloroform  has  been 
under  discussion  ever  since  the  introduction  of  these  agents  as  anes- 
thetics. With  the  introduction  of  etherization  by  the  open  method, 
rebreathing  has  fallen  into  disfavor,  and  many  writers  condemn  it.^ 
When  properly  regulated,  and  when  the  oxygen  supply  is  ample, 
rebreathing  can  be  put  to  a  valuable  use.  The  evidence  in  favor  of  this 
is  derived  partly  from  a  series  of  3,500  nitrous  oxid-oxygen  and  nitrous 
oxid-oxygen-ether  anesthesias  given  by  a  closed  method  at  Halsted's 
clinic,  and  partly  from  the  recent   and  very  important  work  of  the 

^  Taken  from  a  paper  read  before  the  Section  on  Pathology  and  Physiology 
of  the  American  Medical  Association,  at  the  Sixty-second  Annual  Session,  Los 
Angeles,  June,  1911.  Eeprinted,  with  modifications,  by  courtesy  of  J.  Am.  Med. 
Assn. 

^Cunningham   and   Anderson:      "Methods   of   Administering   Ether,"   J.   Am. 
Med.  Assn.,  Nov.  7,  1908,  1574. 

100 


REBREATHING  IN  ADMINISTRATION  OF  ANESTHETICS  101 

physiologists,  Henderson/  Hill,-  Haldane,^  and  others,  on  the  carbon 
dioxid  metabolism  of  the  body. 

ETHER 

The  subject  can  be  approached  most  simply  by  considering  the  harm- 
ful results  supposed  to  follow  the  administration  of  ether  by  the  use  of 
closed  masks.  Ether  only  will  be,  considered  for  the  present,  because 
most  of  the  investigations  bearing  on  the  subject  of  rebreathing  have 
dealt  with  this  anesthetic.  The  ill  effects  in  question  may  be  grouped 
under  two  heads : 

(1)   Injury  to  the  lungs;    (2)  general  toxic  effects. 

Effect  of  Ether  Vapor  on  Respiratory  Passages. — Dreser,*  Oifergeld,^ 
Poppert,^  and  Holscher,'^  have  studied  very  carefully  the  effects  of  ether 
vapor  on  the  respiratory  passages.  Dreser  regards  any  concentration  of 
vapor  which  cannot  be  inhaled  by  the  patient  while  in  the  conscious  state 
without  discomfort  and  coughing  as  harmful  to  the  lungs.  Applying 
this  test  he  fixed  on  6  to  7  per  cent  as  the  highest  concentration  which 
should  be  used.  Offergeld,  experimenting  on  animals,  found  that  the 
lungs,  after  etherization  by  a  closed  method,  showed  much  graver  in- 
juries than  after  etherization  by  an  open  method.  With  the  closed 
method  he  found  extensive  fatty  degeneration  and  desquamation  of  the 
epithelium  of  the  air-passages,  also  many  minute  hemorrhages  into  the 
alveoli;  many  of  the  animals  died  of  bronchopneumonia.  With  the 
open  method  the  pulmonary  lesions  were  of  a  comparatively  unimportant 
character,  unless  the  administration  was  frequently  repeated  at  short 
intervals.  Poppert,  whose  experiments  were  similar  to  Offergeld's,  con- 
cluded that  ether  vapor  was  more  irritating  to  the  lungs  the  greater  its 

'Henderson:  "Acapnia  and  Shock"  (a  series  of  papers),  Am.  J.  Physiol., 
1908,  n,  126;  1909,  ^3,  345;  1909,  ^4,  66;  1910,  f5,  310;  1910,  S6,  385;  1910, 
S6,  260;   1910,  S7,  152. 

2 Hill  and  Flack:  "The  Effect  of  Excess  of  Carbon  Dioxide  and  of  Want 
of  Oxygen  on  the  Eespiration  and  the  Circulation,"  J.  Physiol.,  June  30,  1908; 
"The  Influence  of  Oxygen  Inhalations  on  Muscular  Work,"  J.  Physiol.,  July 
1,   1910. 

"  Haldane  and  Poulton :  * '  The  Effects  of  Want  of  Oxygen  on  Eespiration, ' ' 
J.  Physiol,  1908,  390. 

*  Dreser :  "A  Contribution  to  the  Study  of  Anesthesia  by  Ether, ' '  Johns 
Eoplcins  Hosp.  Bull.,  Jan.,  1895. 

^  Offergeld :  ' '  Lungenkomplicationen  nach  Aethernarkosen, ' '  Arch.  f.  klin. 
Chir.,  1907,  83,  505. 

*  Poppert :  '  *  Experimen telle  und  klinische  Beitrage  zur  Aethernarkose  und 
zur  Aether-Chloroform-Mischnarkose, "  Tfeutsch.  Z.   Chir.,  67,  505. 

'  Holscher :  ' '  Experimentelle  Untersuchungen  iiber  die  Entstehung  der 
Erkrankungen  der  Luf twege  nach  Aethernarkose, ' '  Arch.  f.  klin.  Chir.,  1898,  55, 
175. 


102  ANESTHESIA 

concentration.  Holscher  studied  the  distribution  of  secretion  in  the  air- 
passages  during  ether  narcosis.  He  found  that  there  was  only  a  very 
slight  secretion  from  the  epithelium  situated  below  the  level  of  the 
larynx.  By  putting  coloring  materials  into  the  mouths  of  anesthetized 
animals  he  proved  that  mucus  and  saliva  might  be  aspirated  into  the 
deepest  air-passages.  His  conclusion  was  that  "affections  of  the  air- 
passages  occurring  after  ether  are,  for  the  most  part,  due  to  the  aspira- 
tion of  infectious  mouth  contents." 

The  experimental  results  dealing  with  the  effects  of  ether  vapor  on 
the  lungs  may  be  summarized  as  follows: 

(1)  The  irritant  action  of  the  vapor  varies  according  to  its  concen- 
tration. 

(2)  Post-operative  lung  complications  are  frequently  caused  by  the 
aspiration  of  mouth  contents. 

(3)  The  greater  severity  of  the  pulmonary  lesions  found  after 
experimental  etherizations  by  the  closed  method  can  be  satisfactorily 
accounted  for  by  the  great  concentration  of  ether  vapor  in  the  closed 
masks  and  by  the  greater  liability  to  aspirate  mouth  contents  when  these 
are  used. 

Comparison  of  Toxic  Effects  Following  the  Use  of  Open  and  Closed 
Methods. — We  now  have  to  consider  why  the  general  toxic  effects  which 
follow  ether  anesthesia  are  more  severe  after  the  closed  method  than 
after  the  open  method.  Writers  are  almost  unanimous  in  asserting  that 
this  is  the  case.  The  work  of  Ladd  and  Osgood  ^  is  very  important  in 
this  connection.  These  authors  studied  the  frequency  of  post-anesthetic 
vomiting  in  patients  after  etherization  with  the  Blake  cone,  and  in  those 
etherized  by  the  "gauze  ether"  method.  Vomiting  was  much  more  fre- 
quent and  severe  among  the  former  patients  than  among  the  latter. 
With  the  Blake  cone  cases  they  found  acetone  in  the  urine  after  opera- 
tion in  88  per  cent  of  the  cases,  while  with  the  "gauze  ether"  cases  they 
found  it  in  only  26  per  cent.  The  technique  and  advantages  of  the  open 
method  are  discussed  by  Miss  Magaw,^  who  reports  14,000  cases  with 
most  satisfactory  results.  In  short,  there  is  no  doubt  that  this  method 
of  etherization  is  better  than  the  rather  crude  closed  methods  that  it 
has  replaced.    Its  disadvantages  and  dangers  will  be  referred  to  later. 

The  causes  commonly  held  responsible  for  the  ill  effects  which  follow 
the  closed  method  are  the  following:  (1)  anoxemia;  (2)  overconcen- 
tration  of  ether  vapor;  (3)  toxic  organic  substances  in  the  expired  air; 
and  (4)  excess  of  carbon  dioxid  in  the  expired  air. 

There  is  reason  to  believe  that  the  first  and  second  of  these  possible 
causes  are  the  real  ones.     From  our  present  knowledge,  the  third  is  not 

^Ladd  and  Osgood:     "Gauze  Ether,"  Ann.  Surg.,  Sept.,  1907. 
'  Magaw,  Alice :     "A  Eeview  of  Over  14,000  Cases  of  Surgical  Anesthesia, ' ' 
Surg.,  Gynec.  and  Obstet.,  1906,  3,  795. 


REBREATHING  IN  ADMINISTRATION  OF  ANESTHETICS  103 

important,  since  physiologists  have  demonstrated  that  there  are  no 
organic  poisons  in  the  expired  air,  or  at  least  for  practical  purposes  of 
anesthesia  our  clinical  results  indicate  that  such  substances,  even  if  they 
exist,  need  not  be  seriously  considered.'^  The  excess  of  carbon  dioxid  is 
harmless  and  can  be  utilized  to  good  advantage. 

Effect  of  Overconcentration  of  Ether  Vapor. — It  is  evident  that 
anoxemia  and  overdosage  of  ether — evils  almost  unavoidable  when  this 
anesthetic  is  given  in  a  tightly  closed  mask — must  do  harm.  It  is  known 
that  a  deficiency  of  oxygen  quickly  causes  the  gravest  injuries  to  the 
tissues.  Dreser  found  that  the  gas  within  a  closed  etherizing  mask 
would,  at  times,  put  out  a  burning  candle.  He  also  found  that  the  ether 
vapor  within  the  closed  mask  sometimes  reached  a  concentration  as  high 
as  34  per  cent,  while  6  to  7  per  cent  is  the  greatest  concentration  which 
can  be  inhaled  without  irritation  to  the  air-passages.  With  such  an 
overdosage  of  ether  as  this,  it  is  true  that  the  excess  of  carbon  dioxid 
within  the  closed  mask  is  injurious,  for  it  stimulates  the  respiration 
powerfully,  and  leads  quickly  to  an  overabsorption  of  ether  by  the  blood. 

If  the  truth  of  what  has  just  been  stated  be  admitted,  it  follows  that, 
if  we  can  prevent  anoxemia,  overconcentration  of  vapor,  and  too  great  a 
depth  of  anesthesia,  we  can  obviate  most  of  the  serious  objections  to  the 
closed  method  of  giving  ether. 

NITROUS  OXID,  ALONE  AND  COMBINED  WITH  ETHER 

The  principles  laid  down  in  the  foregoing  paragraphs  have  been  used 
in  developing  a  method  of  anesthesia,  the  technique  and  advantages  of 
which  will  now  be  described.  Nitrous  oxid  and,  if  necessary,  ether  are 
the  anesthetics  used.  The  apparatus  employed  ^  consists  essentially  of  a 
mask  connected  by  a  piece  of  flexible  tubing  to  a  rubber  bag.  This 
forms  a  closed  space  into  which  the  patient  breathes.  On  the  mask  is  a 
valve-box  by  means  of  which  the  patient  can  be  made  to  breathe  to  and 

^  Crowder,  Thomas  K. :  "A  Study  of  the  Ventilation  of  Sleeping-Cars, ' ' 
Arch.  Int.  Med.,  Jan.  15,  1911,  85;  Haldane  and  Smith:  "The  Physiologic 
Effects  of  Air  Vitiated  by  Eespiration, "  J.  Path,  and  Bact.,  1892  and  1893, 
1,  168,  318;  Erclents  Fliigge:  "Eeport  of  Experiments  at  the  Institute  of  Hy- 
giene at  Breslau,"  Z.  f.  Hyg.,  1905,  363,  388,  405  and  433;  Hill  and  Walker: 
"The  Eelative  Influence  of  the  Heat  and  Chemical  Impurity  of  Close  Air,"  J. 
Physiol,  Nov.  9,  1910. 

Rosenau  and  Amos  (J.  Med.  Bes.,  1911,  25,  35)  claim  to  have  found  in  the 
expired  air  minute  quantities  of  organic  matter.  They  expressly  state,  how- 
ever, that  their  work  does  not  necessarily  indicate  that  this  material  is  poison- 
ous.    Their  results  await   confirmation. 

^  The  apparatus  is  described  elsewhere  in  detail.  It  will  be  noted  that  the 
arrangement  for  giving  ether  has  been  changed  so  as  to  permit  of  a  more  ac- 
curate dosage.  The  method  of  administration  is  practically  unchanged,  except 
that  Gatch  now  allows  rebreathing  for  somewhat  longer  intervals. 


104 


ANESTHESIA 


fro  into  the  bag,  or  to  inspire  from  the  bag  and  expire  into  the  air,  thus 
emptying  the  bag.  The  bag  is  attached  to  a  small  box,  through  which 
the  current  of  gas  must  pass  back  and  forth  from  the  bag  to  mask.  Into 
this  box  nitrous  oxid  and  oxygen  are  admitted,  and  ether,  drop  by  drop, 
from  a  receptacle  above.    The  ether  is  vaporized  in  the  box  from  a  series 


Fig.  20. — Gatch  Nitkous  Oxid-Oxygen  Apparatus. 


of  drip-plates  and  any  excess  of  liquid  ether  can  be  drained  off  at  once 
by  a  stopcock. 

Method  of  Administration. — The  mask  is  adjusted  carefully  to  the 
patient's  face  and  the  bag  filled  with  nitrous  oxid  containing  a  very 
small  amount  of  oxygen.  The  patient  is  made  to  breathe  this  mixture 
in  and  out  through  valves,  thus  replacing  all  the  air  in  his  lungs  with 
nitrous  oxid  and  oxygen.  The  bag  is  next  refilled  with  the  same  mix- 
ture of  gases,  which  the  patient  is  made  to  rebreathe  for  from  five 


REBREATHING  IN  ADMINISTRATION  OF  ANESTHETICS  105 

to  eight  minutes.  At  the  end  of  this  time  he  is  allowed  to  empty  the 
bag,  breath  by  breath,  into  the  air,  after  which  it  is  refilled,  and  the 
same  procedure  is  repeated.  Oxygen  is  given,  without  any  attempt  to 
estimate  its  exact  percentage  to  the  nitrous  oxid,  in  quantities  just  suffi- 
cient to  prevent  cyanosis.  If  desired,  nitrous  oxid  can  easily  be  given 
under  positive  pressure,  by  keeping  the  bag  slightly  overdistended. 
This  is  sometimes  a  useful  procedure  in  managing  difficult  cases.  Anes- 
thesia is  usually  established  in  less  than  two  minutes.  If  the  anesthesia 
is  unsatisfactory  with  nitrous  oxid  alone,  ether  is  added.     This  com- 


B.    P. 

PULSE 

X 

o 

200 

190 

180 
170 
150 

160 

140 
130 

120 
110 

100 

160 
160 

140 

130 

120 

110 

100 
80 
80 
70 
60 

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66 

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Fig.  21. — Chart  Showing  Pulse  and  Respiration  with  Rebreathing. 


bined  nitrous  oxid-ether  anesthesia  has  many  points  of  practical  and 
scientific  interest. 

Ether  is  not  given  till  the  patient's  respiration  has  been  stimulated 
by  the  accumulation  of  carbon  dioxid  which  results  from  the  rebreath- 
ing. It  is  then  added  drop  by  drop.  The  heated  gases  quickly  evaporate 
it  from  the  drip  plates,  and  it  is  rapidly  absorbed  by  the  blood  because 
of  the  increased  pulmonary  ventilation.  The  most  difficult  svibjects  can 
thus  be  deeply  anesthetized. 

Basis  of  the  Technique. — Eeference  has  already  been  made  to 
Dreser's  exj)eriments,  in  which  he  proved  that  from  6  to  7  per  cent  of 
ether  vapor  is  the  greatest  concentration  which  can  be  inhaled  by  a 
patient  in  the  conscious  state  without  irritation  and  coughing.  Precau- 
tions must  be  taken  to  keep  the  concentration  of  ether  vapor  in  the  mix- 
ture of  gases  below  this  level  in  order  to  eliminate  the  possibility  of 
injuring  the  lungs.  This  is  quite  easily  accomplished,  as  the  following 
simple  calculation  will  show.  The  gas-bag,  moderately  distended,  holds 
about  10  liters  of  gas,  the  mask  and  tubing  hold  about  1  liter,  and  the 
entire  respiratory  system  of  the  patient  holds  about  3  liters.     When  the 


106 


ANESTHESIA 


patient  is  rebreathing  these  all  form  one  closed  space,  with  a  total 
capacity  of  about  15  liters.  The  problem  therefore  is  simply  to  deter- 
mine how  much  ether  must  be  added  to  15  liters  of  gas  in  order  to  make 
the  concentration  of  ether  vapor  7  per  cent.  Abel  has  calculated  the 
amount  of  ether  to  be  4.2  c.c.  However,  the  conditions  of  the  problem 
are  so  variable  that  the  amount  of  ether  required  cannot  be  determined 
with  absolute  accuracy.  The  varying  temperature  in  the  apparatus,  the 
loss  of  ether  through  leaks  and  by  absorption  in  the  lungs,  are  factors 
for  which  no  accurate  data  can  be 'furnished,  as  they  are  variable.  But 
absolute  accuracy  is  not  necessary,  because  the  constant  loss  of  ether 


• 

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170 
160 
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140 

130 
120 

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Fig.  22. — Chart  of  the  Pulse,  Respiration  and  Blood-Pressure  During  Anesthesia 
OF  Two  Hours  and  Fifteen  Minutes'  Duration.  Pulse:  line  with  crosses.  Res- 
piration: line  with  circles.  Blood-pressure:  line  with  heavy  dots.  The  patient  was  a 
woman  of  65  with  carcinoma  of  the  sigmoid.  The  operation  was  closure  of  a  fecal 
fistula  by  double  lateral  anastomosis,  repair  of  an  old  wound  in  the  abdominal  wall, 
and  colostomy.  Note  the  constant  level  of  the  pulse  and  the  maintained  rise  of  blood- 
pressure.     The  temperature  rose  from  98.6°  to  99.9.°     The  recovery  was  excellent. 


gives  us  a  wide  margin  of  safety,  so  that  ether  can  probably  be  added 
much  faster  than  the  calculation  allows,  without  exceeding  the  danger 
limit. 

Practical  Advice. — With  the  drops  of  ether  falling  at  the  rate  of  130 
to  the  minute,  it  has  been  found  that  it  takes  two  and  one-quarter  min- 
utes to  add  the  4.2  c.c.  Therefore,  if  we  give  ether  at  this  rate  and  take 
precautions  not  to  keep  it  dropping  for  more  than  two  minutes  at  any 
one  time,  and  to  keep  the  bag  constantly  full  of  gas,  we  can  be  sure  that 
the  ether  vapor  will  not  reach  a  concentration  greater  than  7  per  cent. 

The  anesthetist  can  estimate  the  approximate  strength  of  ether  vapor 
by  its  odor  as  it  escapes  from  the  valve-box. 

Maintenance  of  Ether  Balance. — It  has  been  found  unnecessary  to 
give  ether  constantly  during  the  administration.  When  enough  has  been 
given  to  produce  satisfactory  anesthesia,  even  in  cases  requiring  a  deep 
narcosis,  the  anesthesia  can  be  maintained  with  nitrous  oxid  alone. 
This  is  to  be  explained  by  the  fact  that  the  rebreathing  prevents  the 
ether,  once  dissolved  by  the  blood,  from  being  thrown  off  as  rapidly  as 


REBREATHING  IN  ADMINISTRATION   OF  ANESTHETICS  107 


it  would  otherwise  be  by  the  lungs,  which  are 
the  organs  by  which  it  is  practically  all  elim- 
inated.^ Suppose,  for  example,  that  a  patient 
having  a  certain  amount  of  ether  dissolved  in 
his  blood  is  given  some  fresh  nitrous  oxid  and 
oxygen  to  rebreathe.  The  ether  will  be  thrown 
off  from  his  lungs  till  the  tension  of  its  vapor 
in  the  gases  being  breathed  will  equal  that  in 
the  blood.  When  this  occurs  no  more  ether 
will  be  eliminated  until  a  new  supply  of  gas  is 
furnished. 

Elimination  of  Ether  from  the  System. — 
Not  only  can  we  prevent  the  elimination  of 
ether  by  rebreathing,  but  we  can  also  hasten 
the  elimination  by  a  rapid  ventilation  of  the 
lungs  with  fresh  gas.  During  the  process  of 
rebreathing,  carbon  dioxid  accumulates  in  the 
body  and  stimulates  the  respiratory  center  so 
that  the  breathing  becomes  deep  and  rapid — 
often  fifty  or  sixty  respirations  to  the  minute. 
When  a  patient,  anesthetized  in  the  manner 
described,  and  breathing  at  such  a  rate,  is 
given  a  fresh  supply  of  gas  and  allowed  to  dis- 
charge each  breath  into  the  air,  he  apparently 
rapidly  rids  himself  of  the  small  dose  of  ether 
he  has  been  given.  Thus  it  is  possible  to 
anesthetize  a  patient  so  deeply  that  he  will  not 
stir  during  a  Whitehead  or  other  operation  re- 
quiring deep  narcosis,  and  yet  have  him  con- 
scious before  leaving  the  operating  room.  By 
careful  administration  we  can,  in  most  cases, 
keep  the  patient  from  knowing  that  he  has 
been  given  any  ether  at  all,  so  complete  and 
rapid  is  its  elimination. 

It  is  recommended  that  this  method  of  re- 
moving a  volatile  anesthetic  by  rapid  ventila- 
tion of  the  lungs  he  used  at  the  close  of  every 
administration  of  chloroform  or  ether.  The 
increased  pulmonary  ventilation  can  be  easily 


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During  Operation. 


*  Hewitt:  "Anaesthetics  and  Their  Administration,"  3rd  ed.,  50;  Cushny: 
"Pharmacology  and  Therapeutics,"  4th  ed.,  166;  Cushny:  "The  Exhalation  of 
Drugs  by  the  Lungs,"  J.  Physiol.,  40,  17;  Nicloux:  "Elimination  de  Tether 
contenu  dans  le  sang  apres  I'anesthesie  pendant  la  periode  de  retour, "  Cornpt. 
rend.  Soc.  Mol,  1907,  1,  8. 


108  ANESTHESIA 

brought  about  by  making  the  patient  breathe  in  and  out,  through  valves, 
air  or  oxygen  containing  a  small  percentage  of  carbon  dioxid. 

Effect  of  Morphin  on  Ether  Elimination. — In  this  connection,  it  is 
interesting  to  consider  the  effect  which  morphin  has  on  the  elimination 
of  ether  or  chloroform  from  the  body.  Morphin  decreases  markedly  the 
rate  of  pulmonary  ventilation.^  Large  doses  of  this  drug  must  therefore 
retard  the  elimination  of  the  anesthetic  and  thus  increase  its  toxic  action. 
It  is  often  possible  to  detect  the  odor  of  ether  or  chloroform  on  the 
patient's  breath  for  several  hours  after  operation.  This  slow  excretion 
may  be  due,  in  part  at  least,  to  the  morphin,  a  hypodermic  of  which  is 
desirable  before  or  after  almost  every  anesthesia.  Perhaps  this  effect  of 
morphin  can  be  alleviated  by  means  of  the  method  just  described  for 
the  quick  elimination  of  the  anesthetic. 

During  the  stay  of  ether  in  the  system  its  toxic  action  cannot  be 
prevented.  It  has  been  found  that  the  dose  of  ether,  and  its  consequent 
ill  effects,  may  be  reduced  to  the  minimum  by  employing  a  combination 
of  this  agent  with  nitrous  oxid  and  morphin,  the  major  part  of  the 
anesthesia,  in  this  case  being  produced  by  the  nitrous  oxid  and  mor- 
phin. The  effect  of  ether,  when  thus  administered,  is  relatively  much 
greater  than  when  given  alone,  for,  as  is  well  known,  narcotic  drugs, 
given  in  combination,  reinforce  the  action  of  one  another.^  Thus  the 
powerful  joint  effect  of  morphin  and  scopalamin  has  been  explained. 

Clinical  Results. — The  form  of  anesthesia  herein  described  has  been 
in  use  in  the  surgical  clinic  of  the  Johns  Hopkins  Hospital  for  two 
years,  over  2,500  patients  having  been  anesthetized  by  this  method. 
It  is  there  the  routine  form  of  anesthesia  for  all  operations,  except 
those  on  the  face,  upper  air-passages,  or  cranium.  In  these  it  has  been 
found  inconvenient  on  account  of  the  difficulty  of  keeping  the  mask  in 
place. 

Before  the  operation,  the  patient  is  given  an  enema  and  deprived  of 
food  for  several  hours,  but  is  allowed  to  take  small  quantities  of  water. 
About  thirty  minutes  before  the  anesthesia  is  begun  a  hypodermic  of 
morphin  and  atropin  is  given,  the  dose  for  an  adult  being  morphin 
1/6  grain,  atropin  1/100  grain.  The  anesthesia  is  started  after  the 
patient  has  been  placed  on  the  table  and  while  the  field  of  operation  is 
being  surrounded  by  sterile  towels.  It  is  established  so  quickly  that  the 
incision  can  usually  be  made  in  two  minutes  after  the  mask  has  been 
put  on.  Any  depth  of  anesthesia  which  the  condition  of  the  patient  and 
the  nature  of  the  operation  may  require  can  be  easily  obtained,  because 
of  the  control  of  the  patient's  respiration  which  is  given  by  the  rebreath- 

^Cushny:     "Pharmacology  and  Therapeutics,"  4th  ed.,  211. 

^  Fiihner :  ' '  Pharmakologische  Untersuchungen  iiber  die  Mischnarkose, ' ' 
Miinch.  med.  Woch.,  1911,  No.  4;  Biirge:  "Die  Wirkung  von  Narkotikakom- 
binationen,"  Deutsch.  med.  Woch.,  1910,  No.  1,  20;   No.  2,  62. 


REBREATHING  IN  ADMINISTRATION  OF  ANESTHETICS  109 

ing.  In  abdominal  operations,  if  the  increased  activity  of  the  respiration 
is  inconvenient,  it  can  be  prevented  by  giving  a  fresh  supply  of  gas  at 
frequent  intervals.  The  bleeding  during  nitrous  oxid-oxygen  or  nitrous 
oxid-ether  anesthesia  is  about  the  same  as  during  open  ether  anesthesia. 
The  patient's  temperature,  provided  he  is  kept  dry  and  covered,  will  be 
found  elevated  from  0.5°  to  2°  after  an  hour's  operation.  Thus  any 
special  device  for  heating  the  gases  is  unnecessary,  since  the  patient  him- 
self attends  to  this.^  With  light  narcosis,  under  nitrous  oxid  and  oxygen 
alone,  the  pulse  may  be  rapid  (from  140  to  160  to  the  minute),  but  this 
is  of  no  significance,  provided  it  is  regular  and  of  good  quality,  and 
there  is  no  hemorrhage.  The  rapid  heart-rate  decreases  when  ether  is 
given. 

Long  Operations. — This  form  of  anesthesia  is  especially  well  suited 
for  long  operations.  In  fact,  the  anesthesia  does  the  patient  so  little  harm 
that,  within  reasonable  limits,  the  duration  of  the  narcosis  need  not  be 
considered.  This  is  often  advantageous  to  the  surgeon,  when  deliberation 
and  minute  attention  to  detail  are  necessary.  The  following  typical 
cases  illustrate  the  method: 

Case  1. — The  patient  was  a  negro  man,  aged  27,  in  good  physical 
condition.  Operation:  Excision  of  a  sarcoma  from  the  right  popliteal 
space,  and  blood-vessel  transplantation.  Duration  of  anesthesia,  five 
hours.  The  pulse-rate  per  minute  varied  from  72  to  100.  The  blood- 
pressure  at  the  end  of  four  hours  of  anesthesia  was  130  mm.  of  mercury. 
The  patient  regained  consciousness  before  leaving  the  table.  He  had  no 
headache,  nausea,  or  vomiting  though  he  was  given  water  at  once.  His 
urine  after  operation  contained  no  albumin  or  acetone.  He  was  allowed 
to  rebreathe  at  two  and  one-half  and  three-minute  intervals.  The  nar- 
cosis was  deep  and  quiet.  Ether  was  given  with  the  gas  for  the  first 
half  hour. 

Case  2. — The  patient  was  a  white  woman,  aged  30,  in  rather  poor 
condition.  Operation:  Eesection  of  the  ascending  and  transverse  colon. 
Duration  of  anesthesia,  two  hours  and  five  minutes.  No  ether  was  used. 
The  narcosis  was  light,  the  patient  at  times  moving  her  limbs.  Eecovery 
was  immediate  and  unattended  with  headache  or  vomiting. 

Case  3. — The  patient  was  a  colored  woman,  aged  30,  in  good  con- 
dition. Operation :  Excision  of  the  right  breast,  pectoral  muscles  and 
axillary  glands  for  advanced  cancer  of  the  breast,  Thiersch  skin  graft- 
ing of  the  raw  surface  of  the  breast.  Duration  of  anesthesia,  three 
hours  and  fifty-five  minutes ;  21/0  ounces  of  ether,  130  gallons  of  gas 
and  30  of  oxygen  were  used.  The  anesthesia  was  quiet  and  satisfac- 
tory, the  recovery  immediate  and  without  headache,  nausea,  or  vom- 
iting. 

^On  the  subject  of  "Warmed  Anesthetic  Vapor,"  see  Gwathmey,  N.  Y,  J. 
Of  Med.,  Feb.,  1905. 


no  ANESTHESIA 

Cautions. — A  word  of  caution  is,  however,  necessary.  During  any. 
administration,  and  especially  during  a  long  administration,  the 
patient's  breathing  must  be  kept  free  and  unobstructed,  and  his  color 
good.  If  a  patient  has  to  work  hard  for  every  breath  he  soon  wears 
himself  out..  The  color  of  the  blood  in  the  wound,  the  hue  of  the 
patient's  face,  and  the  character  of  his  breathing,  as  shown  by  the 
movements  of  the  rubber  bag,  are  the  best  indicators  of  his  condition. 
The  surgeon  himself  can  hardly  fail  to  notice  these.  If  the  patient's 
breathing  cannot  be  kept  unobstructed,  the  use  of  the  apparatus  should 
be  abandoned  at  once  and  some  other  method  for  the  production  of 
anesthesia  employed. 

Fatalities. — Three  fatalities,  during  or  immediately  after  operation, 
in  the  series  of  3,500  cases  have  been  recorded.  How  much  the  an- 
esthesia was  to  blame  for  these  may  be  judged  from  the  following 
reports : 

Fatality  1. — The  patient  was  a  colored  woman,  aged  44,  with  ex- 
ophthalmic goiter  of  four  years'  standing.  She  had  an  irregular  inter- 
mittent pulse,  the  rate  of  which  had  been  between  120  and  140.  Her 
heart  was  enlarged,  and  she  had  ascites  and  edema  of  the  ankles.  Dur- 
ing the  last  week  of  her  life  she  had  several  severe  attacks  of  dyspnea, 
associated  with  extreme  rapidity  and  irregularity  of  the  pulse.  For 
these  she  was  given  a  course  of  digitalis,  which  improved  her  condition 
so  much  that  it  was  thought  she  could  withstand  a  partial  thyroidectomy. 
When  the  mask  was  placed  over  her  face,  she  made  a  very  slight  struggle 
and  took  several  shallow  breaths.  The  operator  then  saw  the  superficial 
veins  of  her  neck  suddenly  dilate.  This  apparently  marked  the  time 
of  death,  and  occurred  within  half  a  minute  of  the  time  the  anesthetic 
was  started. 

Fatality  2. — The  patient  was  a  man  with  aortic  and  mitral  insuf- 
ficiency, on  whom  it  was  proposed  to  do'  a  perineal  prostatectomy.  He 
was  given  ether  with  the  gas  and  oxygen.  The  anesthesia  went  very 
well  till  the  patient  was  placed  on  the  perineal  table  with  his  buttocks 
elevated;  then  he  became  cyanotic  and  died.  An  immediate  autopsy 
revealed  the  presence  of  a  large  pericardial  effusion,  the  presence  of 
which  had  not  been  recognized  before  the  operation. 

Fatality  3. — The  patient  was  a  girl  of  16,  with  multiple  infectious 
arthritis;  general  condition  poor.  Operation:  Injection  of  both  knees 
with  oil  and  manipulation  of  knees,  ankles,  and  elbows.  Duration  of 
anesthesia,  fifteen  minutes.  The  anesthesia  was  uneventful,  except  for 
a  marked  increase  in  pulse-rate  while  each  joint  was  being  manipu- 
lated. At  no  time  was  the  breathing  obstructed.  At  the  close  the  pulse- 
rate  went  up  very  rapidly;  the  color  became  cyanotic  and  could  not  be 
cleared  up  with  oxygen.  The  breathing  became  weaker  and  weaker, 
and  finally  ceased.    An  autopsy  showed  a  very  large  thymus  and  hyper- 


REBREATHING  IN  ADMINISTRATION  OF  ANESTHETICS  111 

trophy  of  all  the  lymphatic  tissues.  The  pathologists  gave  status  lyrn- 
pliaticus  as  the  cause  of  death. 

The  first  and  second  of  these  patients  had  circulatory  disease  of 
such  gravity  that  the  anesthesia  is  not  to  be  seriously  blamed  for  the 
deaths.  How  the  third  fatality  was  brought  about  it  is  hard  to  under- 
stand. The  toxicity  of  nitrous  oxid  is  certainly  too  low  to  have 
caused  it. 

Cardiac  Cases. — ISTotwithstanding  these  fatalities,  it  is  believed  that 
this  form  of  anesthesia,  properly  employed,  is  well  suited  for  cardiac 
cases.  Two  cases  of  Cesarean  section  performed  by  J.  W.  Williams  on 
women  with  serious  valvular  lesions  will  show  the  grounds  for  this  belief. 
Both  women  were  in  about  the  seventh  month  of  pregnancy,  and  in 
both  delivery  was  necessary  in  order  to  save  the  life  of  the  patient. 
One  patient  was  in  extremis  and  her  death  on  the  table  was  regarded 
by  the  operator  as  probable.  Both  women  had  such  urgent  dyspnea 
that  the  anesthetic  had  to  be  started  with  the  patient  sitting  upright. 
The  same  method  of  administration  was  employed  in  each  case.  Each 
patient  was  given  a  hypodermic  of  morphin  large  enough  to  quiet 
her.  In  inducing  anesthesia  great  care  was  exercised  to  avoid  the  least 
excitement  or  struggling  on  the  part  of  the  patient.  Both  were  allowed 
to  rebreathe  oxygen  till  the  respiration  was  stimulated  before  any  nitrous 
oxid  was  given.  Enough  ether  was  used  to  give  a  quiet  anesthesia. 
The  operations  were  performed  with  the  patients'  bodies  elevated  at  an 
angle  of  20°  to  30°.  The  pulse  of  both  patients  was  much  better  during 
anesthesia  than  before,  and  the  operator  was  able  to  proceed  without 
undue  haste.     Both  patients  made  an  excellent  recovery. 

Hypercapnia. — Clinical  experience  has  certainly  shown  that  an  excess 
of  carbon  dioxid  in  the  blood — a  hypercapnia  during  anesthesia  to  the 
degree  allowed — is  harmless.  Hill  and  Flack  state  that  "the  effects  of 
carbon  dioxid  on  the  heart  can  always  be  quickly  recovered  from,  even 
if  the  blood-pressure  has  sunk  to  zero."  These  authors  found  that  car- 
bon dioxid  up  to  a  percentage  of  35  in  the  air  breathed  stimulates 
the  respiration,  while  above  35  it  depresses  it;  also  that  percentages  up 
to  22  produce  a  rise  in  blood  pressure,  while  higher  percentages  cause 
a  fall.  Of  course  it  is  impracticable  to  determine  exactly  what  per- 
centage of  carbon  dioxid  a  patient  is  breathing.  The  anesthetist  must 
regulate  the  time  of  rebreathing  so  that  the  patient's  respiration  is 
moderately  stimulated.  The  periods  of  rebreathing  for  10  liters  of 
gas  range  from  three  to  five  minutes,  any  leakage  from  the  apparatus 
being  meanwhile  made  up  by  the  addition  of  fresh  gas.^ 

^  Alter  rebreathing  10  liters  of  oxygen  for  three  minutes,  it  was  found  to  con- 
tain 8.9  per  cent  CO  .  Allowing  for  the  decreased  CO^  formation  during  anes- 
thesia, it  is  probable  that  the  percentage  breathed  by  the  patient  is  seldom 
above  this. 


112  ANESTHESIA 

Acapnia. — Does  a  deficiency  of  carbon  dioxid  in  the  blood — acapnia 
— do  serious  harm?  Henderson  has  been  able  to  reduce  animals  to  a 
state  of  extreme  shock  by  overventilation  of  their  lungs.  He  asserts 
that  acapnia  causes  complex  osmotic  changes  in  the  tissues,  which  result 
in  a  passage  of  water  from  the  blood  into  the  lymph  and  into  the  tissue- 
cells,  and  a  dilatation  of  the  finer  veins.  Interference  with  the  normal 
filling  of  the  right  side  of  the  heart  by  this  process  is  the  essential  phe- 
nomenon in  surgical  shock.  In  extreme  cases  of  acapnia  the  blood- 
stream is  so  scant  and  the  respiration  so  feeble  that  the  tissues  do  not 
receive  the  necessary  amount  of  oxygen.  An  asphyxial  acidosis  results 
which  does  the  body-cells  irreparable  injury.  Whether  Henderson's 
theory  be  accepted  or  not  it  must  be  admitted  that  the  accumulation  of 
carbon  dioxid  by  the  process  of  rebreathing  is  an  efficient  stimulus  to 
the  respiration  and  circulation.  In  fact,  it  is  used  as  a  purely  thera- 
peutic measure  in  cases  of  morphin  poisoning,  in  cases  of  so-called 
traumatic  or  toxemic  shock,  and  wherever  the  respiration  is  feeble.^ 
Oxygen  can  be  given  much  more  effectually  and  cheaply  by  the  use  of 
rebreathing  than  in  the  ordinary  way.  Thus,  with  anesthetics  of  low 
toxicity  and  the  use  of  rebreathing,  a  very  ill  patient  may  be  benefited 
by  an  anesthetic. 

Ether  and  Acapnia. — On  the  other  hand,  when  ether  is  given  by  the 
open  method,  we  take  a  very  efficient  means  of  producing  acapnia, 
because  ether  diminishes  the  formation  of  carbon  dioxid  by  the  tissues, 
and,  by  stimulating  the  respiration,  hastens  its  elimination.  Symptoms 
of  a  mild  grade  of  acapnia  under  open  ether  anesthesia  are  com- 
mon. Thus  a  patient  who  has  perhaps  been  difficult  to  anesthetize, 
or  who  has  been  lightly  under  ether  for  some  time  and  is  breathing 
at  a  rapid  rate,  will  gradually  stop  breathing.  After  an  interval  of 
perhaps  two  or  three  minutes,  his  respiration  will  start  again  but  will 
not  be  normal  for  a  long  time.  This  occurrence,  though  alarming,  is 
seldom  followed  by  harmful  results. 

Hundreds  of  patients  are  etherized  daily  by  the  open  method  without 
developing  symptoms  of  shock.  What  prevents  a  serious  grade  of 
acapnia  in  the  great  majority  of  cases  ?     Several  factors  are  concerned.- 

(1)  Many  anesthesias  are  of  too  brief  duration  for  acapnia  to 
develop. 

(3)  There  is  frequently  more  or  less  obstruction  to  the  breathing 
during  narcosis,  and  this  prevents  acapnia. 

^Patients  with  feeble  pulse  and  respiration — so-called  shock  cases — should 
be  made  to  rebreathe  air  in  oxygen  till  their  respiration  is  normal,  before  breath- 
ing the  anesthetic. 

^Levi,  Ettore:  "Studies  on  the  Patho-physiologic  Action  of  CO^  and  on 
the  Therapeutic  Applications  in  Surgery  and  Medicine  of  Mixture  of  O2  and 
CO2,"  Estr.  d.  rev.  crit.  di  din.  med.,  1910,  11,  30,  31. 


REBREATHING  IN  ADMINISTRATION  OF  ANESTHETICS  113 

(3)  The  slowing  of  the  respiration  which  results  from  a  prelim- 
inary hypodermic  of  morphin  may  protect  from  the  same  danger/ 

(4)  The  so-called  "open"  method  is  usually  not  "open"  at  all,  for 
the  mask  is  so  covered  with  towels  or  gauze  that  the  patient  does  con- 
siderable rebreathing. 

Other  Advantages  of  Rebreathing. — Apart  from  the  prevention  of 
acapnia,  rebreathing  presents  several  other  advantages  over  open  ether 
anesthesia.    The  chief  of  these  ar&: 

(1)   Lessened  post-anesthetic  vomiting. 

(3)  Decrease  in  number  of  cases  of  abdominal  distention  after 
operation. 

(3)   Practical  abolition  of  post-anesthetic  lung  complications.- 

Post-Anesthetic  Nausea. — Vomiting  after  operation  depends  on 
many  things  besides  the  anesthetic.  About  35  per  cent  of  our  patients 
vomit,  but  the  vomiting  is  usually  very  slight.  Of  200  patients  only  four 
had  more  than  very  transient  vomiting.  Of  these  cases  one  was  a  case 
of  exophthalmic  goiter,  one  a  case  of  stone  in  the  common  bile-duct,  one 
a  case  of  spreading  peritonitis  from  an  appendix  abscess,  and  one  a 
case  of  intestinal  reaction.  The  naasea  alone  seldom  prevents  a  patient 
from  taking  water  and  nourishment  at  once  after  operation. 

Post-Anesthetic  Abdominal  Distention. — Very  little  experimental 
work  has  been  done  regarding  the  question  of  abdominal  distention 
following  ether  anesthesia.  Cannon  and  Murphy  ^  observed  a  great  delay 
in  the  emptying  of  the  stomach  contents  into  the  duodenum,  and  a 
slowing  of  the  passage  of  food  along  the  intestines  after  etherization. 
Figure  24,  which  is  a  tracing  obtained  from  D.  E.  Hooker,''  demonstrates 

^Crile:     "The  Blood-pressure  in  Surgery,"  281. 

^  Homans :  * '  Post-Anesthetic  Pulmonary  Complications, ' '  Bull.  Johns  Hop- 
Mns  Eosp.,  April,  1909. 

^  Cannon  and  Murphy :  ' '  The  Movements  of  the  Stomach  and  Intestines  in 
Some  Surgical  Conditions,"  Ann.  Surg.,  1906,  13,  513. 

*  Thanks  are  due  Dr.  Hooker  for  permission  to  publish  this  tracing  and  for 
the  following  note: 

' '  Dr.  Gatch  has  asked  to  have  added  a  note  covering  some  unpublished  experi- 
ments done  in  the  physiologic  laboratory  of  the  Johns  Hopkins  University,  which 
appear  to  have  a  direct  bearing  on  his  own  work. 

' '  Cross-sections  of  blood  vessels  or  intestine,  to  which  a  recording  lever  was 
attached,  were  hung  in  a  moist  chamber.  In  the  use  of  tissue  from  warm- 
blooded animals  the  temperature  of  the  chamber  was  maintained  constant  at  35° 
C.  Through  the  chamber  were  passed  alternately  streams  of  oxygen  and  carbon 
dioxid  gas.  By  this  method  the  tissue  studied  was  exposed  to  practically  pure 
atmospheres  of  the  gases.  The  experimental  conditions,  therefore,  did  not  fall 
within  physiologic  limits,  so  far  as  the  percentage  of  gas  is  concerned.  Work 
is  now  in  progress  to  investigate  the  effect  of  different  percentages  of  oxygen 
and  carbon  dioxid.  Aside  from  the  result  of  this  future  work,  however,  the 
interesting  fact  has  been  demonstrated  that  the  musculature  of  the  blood  vessels 
responds   in   atmospheres   of   the   gases   studied   in   an   exactly    opposite   manner 


114  ANESTHESIA 

the  paralyzing  effect  of  a  weak  ether  vapor  on  the  pyloric  ring  of  the 
frog.  It  also  shows  that  carbon  dioxid  acts  as  a  powerful  stimulant  to  the 
muscle  of  the  ring.  Of  course  the  conditions  to  which  the  bowel  was 
subjected  when  this  tracing  was  obtained  were  abnormal,  yet  the  paraly- 
sis by  ether  -is  exactly  what  any  clinician  would  expect.  It  is  well  recog- 
nized that  an  excess  of  carbon  dioxid  in  the  blood  promotes  peristalsis, 


Fig.  24. — Tracing  Obtained  from  the  Pyloric  Ring  of  a  Frog  Suspended  in  a  Moist 
Chamber  into  Which  Ether  Vapor  and  Carbon  Dioxid  Could  Be  Passed.  At  c, 
carbon  dioxid  was  passed  over  the  muscle,  causing  a  sharp  contraction ;  at  ei  very  dilute 
ether  vapor  was  turned  on  with  the  carbon  dioxid,  causing  immediate  relaxation;  at  62 
the  ether  was  turned  off. 

to  the  musculature  of  the  intestines.  Carbon  dioxid  causes  a  marked  improve- 
ment in  the  tone  of  the  intestines  and  a  m^arked  relaxation  of  tone  in  the  veins 
and  arteries.  On  tlie  other  hand,  oxygen  causes  a  relaxation  of  tone  in  the 
intestines  and  an  improvement  of  tone  in  the  veins  and  arteries.  These  results 
were  obtained  in  the  case  of  both  warm-blooded  and  cold-blooded  animals  and 
demonstrated  with  graphic  records. 

"If  it  be  true  that  Henderson  reasoned  by  analogy  from  the  behavior  of 
the  smooth  muscle  in  the  intestine  to  that  in  the  blood  vessel  (especially  the 
veins)  in  developing  the  acapnia  theory  of  surgical  shock,  it  is  obvious  from 
these  results  that  his  reasoning  was  not  entirely  justifiable. 

"The  correlation  of  the  difference  in  action  of  these  gases  in  physiologic 
economy  tempts  speculation.  The  body  seeks  to  rid  itself  of  any  excess  of  car- 
bon dioxid.  Jerusalem  and  Starling  {J.  Physiol.,  1910,  40,  279)  have  shown 
that  carbon  dioxid  (0.625  of  an  atmosphere)  increases  the  efficiency  of  the 
isolated  mammalian  heart  chiefly  by  improving  its  diastolic  relaxation.  Bayliss 
(J.  Physiol.,  1901,  26,  32)  has  shown  that  this  gas  relaxes  vascular  tone.  It, 
has  long  been  known  that  in  the  intestine  the  same  gas  increases  peristalsis,  and 
Mall  {Johns  HopMns  Eosp.  Bep.,  1896,  1,  37)  has  suggested  that  rhythmic  move- 
ments of  the  intestines  may  help  to  empty  the  venous  plexuses  in  the  walls  and 
thus  aid  in  driving  the  blood  into  the  portal  system.  We  have,  therefore,  a 
coordination  of  activity  which  greatly  facilitates  the  circulation  of  blood  and 
the  consequent  rapid  elimination  of  the  carbon  dioxid.  Oxygen  in  excess,  on 
the  contrary,  would  tend  to  bring  about  opposite  effects  with  a  resultant  retarda- 
tion of  the  circulation. 

"In  conclusion,  it  should  be  clear  to  the  reader  that  this  is  a  chemical  regu- 
lation of  the  circulation  entirely  peripheral  in  its  action.  The  action  of  the 
gases  on  the  medullary  centers  is  a  wholly  different  question." 


REBREATHING  IN  ADMINISTRATION   OF  ANESTHETICS  115 

aud  Henderson^  has  shown  that  the  noriual  ijitcstinal  movements  wliieh 
cease  after  a  laparotomy  can  be  restored  by  passing  a  stream  of  carbon 
dioxid  over  the  exposed  bowel.  These  experimental  results  are  con- 
firmed by  clinical  experience.  It  will  be  recalled  that  we  use  the  smallest 
possible  amount  of  ether,  and  produce  a  hypercapnia  by  making  a  patient 
rebrcathe.  In  the  200  cases  referred  to  above  there  was  not  a  case  of 
abdominal  distention  except  after  laparotomy,  and  among  the  laparoto- 
mies, seventy-five  in  number,  it  occurred  in  but  three  cases,  these  being 
the  same  patients  who  had  considerable  vomiting. 

Post-Anesthetic  Lung  Complications. — In  2,500  cases  of  nitrous 
oxid-oxygen  or  nitrous  oxid-oxygen-ether  anesthesia  there  was  but 
one  case  of  post-anesthetic  pneumonia;  this  wa,s  in  a  girl  with  general 
peritonitis,  who  recovered.  This  absence  of  pneumonia  may  have  been 
partly  accidental,  since  pneumonia  after  operation  may  be  due  to  causes 
other  than  the  anesthetic.  The  record  is  striking,  however,  and  all  the 
more  so  because  patients  wath  pulmonary  tuberculosis,  bronchitis,  and 
empyema  were  anesthetized  without  hesitation.  It  contrasts  markedly 
with  the  record  after  open  ether.  Here  in  a  series  of  400  cases  there  was 
one  death  from  ether  pneumonia,  and  two  deaths,  one  with  autopsy,  from 
acute  pulmonary  tuberculosis.^  The  latter  patients  were  both  operated 
on  for  tuberculous  glands  of  the  neck.  Both  patients  died  rather  late — 
in  from  two  to  three  weeks — after  operation,  bvit  they  ran  a  high  tem- 
perature from  the  first.  It  was  the  oj^inion  of  L.  Y.  Hammond,  who 
had  charge  of  the  work  on  tuberculosis  at  the  Johns  Hopkins  Hospital, 
that  the  etherization  had  lighted  up  small  apical  foci  of  disease  un- 
detected before  operation. 

Method  Demands  Experience. — The  impression  must  not  be  gained 
that  this  form  of  anesthesia  is  free  from  danger.  It  is  without  danger 
so  far  as  post-operative  effects  are  concerned.  During  the  administra- 
tion, however,  there  are  dangers.  These  arise  from  causes  which  can 
generally  be  foreseen  and  which  can  always  be  j)revented  by  careful  and 
skillful  administration.  The  method  should  not  be  used  except  by  those 
who  have  made  a  special  study  of  its  problems. 

CHLOROFORM  AND   ETHYL  CHLORID 

Suggested  Investigations. — The  foregoing  discussion  of  the  use  of 
rebreathing  in  the  administration  of  ether  and  nitrous  oxid  will  apply, 
in  part  at  least,  to  the  administration  of  all  anesthetics  given  by  inhala- 
tion.    It  would  seem  that  rebreathing  in  the  administration  of  chloro- 

^  Henderson :  "Shock  after  Laparotomy:  Its  Prevention,  Production,  and 
Eelief,"  Am.  J.  Physiol.,  1909,  21,  60. 

^  Walsh :  '  *  Chloroform  Eather  Than  Ether  Anesthesia  in  Tuberculosis, ' ' 
J.  Am.  Med,  Assn.,  Aug.  28,  1909. 


116  ANESTHESIA 

form  and  ethyl  chlorid  would  be  attended  by  the  same  advantages  that 
exist  in  the  giving  of  ether  and  nitrous  oxid.  The  general  principles 
which  govern  the  administration  of  these  agents  by  a  closed  method  are : 

First:  The  problem  of  dosage,  which  must  be  taken  into  account 
because  of  the  high  toxicity  of  chloroform  and  ethyl  chlorid.  A  definite 
measured  quantity  of  the  anesthetic  should  be  added  to  each  measured 
volume  of  the  gas  which  serves  as  a  vehicle  for  administering  it.  The 
narcosis  should  be  begun  with  a  very  dilute  anesthetic  vapor. 

Second:  AVhen  once  anesthesia  is  established,  it  should  be  main- 
tained in  the  same  way  as  with  an  ether  anesthesia,  namely,  by  pre- 
venting the  elimination  of  the  drug  from  the  patient's  blood  by  making 
him  rebreathe  oxygen  or  air.  The  elimination  of  the  anesthetic  at  the 
close  of  the  narcosis  could  be  hastened  by  overventilation  of  the  patient's 
lungs. 

Dangers. — The  chief  dangers  of  this  method  are: 

(1)  Anoxemia  due  to  a  failure  to  give  sufficient  oxygen  or  to  an 
obstructed  airway. 

(2)  Impediments  to  the  respiration,  which,  in  a  long  anesthesia,  may 
exhaust  the  patient. 

(3)  With  cardiac  cases,  .excitement  during  the  period  of  induction. 
Advantages. — The  chief  advantages  of  this  method  are : 

(1)  The  rapidity  and  pleasantness  with  which  anesthesia  is  estab- 
lished. 

(2)  The  ease  with  which  any  depth  of  anesthesia  can  be  secured. 

(3)  The  prevention,  to  a  very  large  extent,  of  post-anesthetic  vom- 
iting, pulmonary  complications,  and  abdominal  distention. 


CHAPTER    TV 

NITEOUS    OXID 

HiSTOEY :  Early  Use  in  Dentistry ;  Nitrons  Oxid  Administered  with 
Oxygen;  Physical  Properties;  Chemical  Properties;  Impurities  of 
Nitrous  Oxid;  Standard  of  Purity. 

Special  Physiology:  The  Hyperoxygenation  Theory;  The  De- 
oxygenation  or  Asphyxiation  Theory ;  The  Theory  of  the  Specific  Action 
of  Nitrous  Oxid  upon  the  Brain  Cells;  Effects  upon  the  Respiratory 
System;  Effects  upon  the  Circulatory  System;  Effects  upon  the  Nervous 
System ;  Effects  upon  the  Muscular  System ;  Effects  upon  the  Glandular 
System  and  Other  Structures;  Causes  of  Death;  Stages  of  Anesthesia; 
Elimination ;  After-effects. 

Comparison  with  Other  Agents. 

Indications  and  Contraindications. 

Administration  :  Heating  the  Gas ;  Essential  Features  of  Any 
Satisfactory  Apparatus;  Apparatus  for  Administering  Nitrous  Oxid 
Alone  or  With  Air;  Dangers  of  Administration  of  Nitrous  Oxid  Alone; 
Recognition  of  Asphyxial  Symptoms;  Administration  of  Nitrous  Oxid 
Alone;  Administration  to  Asphyxiation  With  and  Without  Valves;  Use 
of  Expiratory  Valve  Alone;  Administration  Without  Valves;  Precau- 
tions When  Administered  Alone;  Administration  of  Nitrous  Oxid  With 
Air  in  Unknown  Quantities ;  Administration  of  Nitrous  Oxid  With  Defi- 
nite Amounts  of  Air;  Nitrous  Oxid  as  a  Sequence  to  Ether;  Nitrous 
Oxid  With  Air;  Technique  of  Ether-Nitrous  Oxid  (Air)  Sequences; 
Technique  With  A.C.E. ;  Advantages  of  Ether  (or  Chloroform-Ether) - 
Nitrous  Oxid  Sequence;  The  Advantages  of  Administration  of  Nitrous 
Oxid  With  Oxygen;  Superiority  of  Oxygen  Over  Air;  The  Administra- 
tion of  Nitrous  Oxid  With  Indefinite  Quantities  of  Oxygen;  Catch's 
Method  of  Administration;  Davis'  Method;  Methods  of  Administration 
With  Definite  (Quantities  of  Nitrous  Oxid  and  Oxygen;  Gwathmey's 
Method;  Teter's  Method;  Technique  to  be  Followed  in  Administering 
Nitrous  Oxid  and  Oxygen  With  the  Teter  Apparatus  and  the  Teter  Nasal 
Inhaler;  Nitrous  Oxid  Oxygen  Endopharyngeally ;  Boothby,  and  Cotton 
Apparatus;  The  Gwathmey-Woolsey  Nitrous  Oxid-Oxygen  Apparatus. 

117 


118  ANESTHESIA 


HISTORY 


In  1772,  Priestley  ^  discovered  nitrous  oxid,  called  by  him  "dephlo- 
gisticated  nitrous  air,"  by  reducing  nitrogen  dioxid  (NOo),  "gaseous 
oxide  of  azot/'  with  moist  iron  filings.  In  1793,  Deimann  and  others 
prepared  the  gas  by  heating  ammonium  nitrate  (]SrH4N03),  essentially 
the  commercial  process  for  its  manufacture  to-day. 

In  1798,  the  "Pneumatic  Institute"  was  founded  for  the  purpose 
of  investigating  the  "medical  powers  of  factitious  airs  or  gases"  and  was 
set  up  at  Clifton  by  Dr.  Beddoes.  The  immediate  idea  to  be  followed 
out  was  the  treatment  of  phthisis  and  other  lung  troubles  by  inhalation 
of  various  gases.  Humphrey  Davy  was  assigned  the  office  of  superin- 
tending the  experiments.  One  of  the  first  outcomes  of  his  researches, 
the  result  of  his  experimentation  with  nitrous  oxid  upon  animals,  is 
given  in  the  f olloAving  historical  and  often  qiioted  sentence  :^  "As  nitrous 
oxid  in  its  extensive  operation  appears  capable  of  destroying  physical 
pain,  it  may  probably  be  used  to  advantage  during  surgical  operations  in 
which  no  great  effusion  of  blood  takes  place."  Then  Davy  actually 
inhaled  the  gas  and  recorded  his  own  sensations  and  the  behavior  of 
others  after  they  had  inhaled  it. 

Early  Use  in  Dentistry. — In  Decembisr,  1844,  Colton  delivered  a  lec- 
ture on  nitrous  oxid  and  other  gases  in  Hartford,  Connecticut.  Horace 
Wells,  a  dentist  of  that  place,  was  present.  He  noticed  that  a  person 
under  the  influence  of  the  gas  was  capable  of  sustaining  a  severe  injury 
without  apparently  feeling  any  pain.  This  fact  so  impressed  him  that 
he  requested  Colton  to  administer  the  gas  to  him,  and,  while  under  its 
influence,  had  a  tooth  extracted  without  feeling  the  least  pain.  Upon 
regaining  consciousness,  he  exclaimed,  "A  new  era  in  tooth-pulling." 
From  that  time  on  he  administered  the  gas  to  his  patients  with  more  or 
less  success.^  With  the  death  of  Wells,  which  occurred  in  1848,  and 
the  introduction  of  ether,  nitrous  oxid  was  not  thought  of  again  as  an 
anesthetic  until  Colton  revived  its  use  in  1863.  Kymer  in  England  and 
Hermann  in  Germany  also  imdertook  (18G4-1866)  some  experiments 
with  nitrous  oxid. 

^"Experiments  and  Observations  on  Different  Kinds  of  Air,"  1,  3;  "Mem- 
oirs of  Joseph  Priestley  to  the  Year  1795,"  1803,  1. 

^Davy:  "Eesearches,  Chemical  and  Philosophical,  Chiefly  Concerning  Nitrous 
Oxide,"  London,  1800. 

^IJpon  attempting  to  make  a  public  exhibition  at  the  Massachusetts  General 
Hospital  the  inhaler  was  removed,  possibly  too  soon,  and  the  patient  gave  a 
piercing  cry.  Wells  was  immediately  looked  upon  as  an  imposter.  He,  a 
modest,  retiring  man,  felt  the  imputation  deeply,  and,  while  continuing  to  ad- 
minister the  gas  in  private,  never  summoned  sufficient  courage  to  attempt  an- 
other public  exhibition.  Later  he  gave  up  the  practice  of  dentistry,  became 
more  or  less  unsettled  in  his  mind,  and  died  by  his  own  hand. 


NITROUS   OXID 


119 


In  1867^  Colton  was  able  to  give  a  record  of  twenty  thousand  suc- 
cessful cases;  and  in  1868  an  auspicious  demonstration  took  place  at 
the  Dental  Hospital  in  London,  mainly  through  the  financial  assistance 
and  patronage  of  the  well-known  American  dentist,  Evans,  of  Paris. 
At  this  period  it  was  considered  safe  for  short  operations.  Some  sur- 
geons, however,  declaimed 
against  nitrous  oxid  as  unsatis- 
factory and  dangerous.  Never- 
theless, a  Joint  Committee  of 
the  Odontological  Society  and 
of  the  Dental  Hospital  reported 
so  favorably  upon  the  value  of 
the  gas  that  it  has  since  occu- 
pied the  foremost  place  as  an 
anesthetic  in  modern  dentistry 

Nitrous  Oxid  Administered 
with  Oxygen. — In  1868,  An- 
drews published  accounts  of  a 
number  of  cases  in  which  he 
had  obtained  a  non-asphyxial 
form  of  anesthesia  by  using  oxy- 
gen with  nitrous  oxid. 

It  is  now  well  established 
that  an  efficient  anesthesia  can 
be  maintained  by  administering 
definite  percentages  of  air  with 
the  gas.  Also,  by  combining 
nitrous  oxid  with  oxygen  we 
may  obtain  a  deeper,  more  satisfactory  and  safer  anesthesia.  Further- 
more, by  warming  a  mixture  of  the  gas  and  oxygen,  and  by  the  addition 
of  small  amounts  of  ether  and  chloroform,  a  satisfactory  form  of  anes- 
thesia can  be  maintained  for  over  80  per  cent  of  all  surgical  cases. 
Brown,  of  Cleveland,  Ohio,  was  the  first  to  use  a  warmed  mixture  of 
nitrous  oxid  and  oxygen.^  Clover  and  Coleman  first  attempted  the  con- 
tinuous administration  of  nitrous  oxid  through  the  nose.  Patterson,  in 
1899,  improved  upon  this,  and  Kilpatrick,^  in  1902,  still  further  im- 
proved this  method  by  placing  a  regulation  expiratory  valve  upon  the  nose- 
piece.  Teter  improved  the  technique  of  nasal  anesthesia  by  using  oxygen 
and  warm  nitrous  oxid  with  a  perfected  nosepiece.  Karl  Connell,  of 
Eoosevelt  Hospital,  has  only  recently  improved  the  technique  of  admin- 
istering nitrous  oxid  and  oxygen  by  using  nasal  catheters  and  a  pharyn- 

^  The   first   recorded   experimentation   with   these   gases   at   different   tempera- 
tures on  lower  animals  was  by  Gwathmey  in  1906. 
"Medical  Press,  July  18,  1902. 


Fig.  25. — Gardner  Q.  Colton. 


120  ANESTHESIA 

geal  breathing  tube  to  maintain  a  clear  airway  and  also  by  rebreathing 
to  decrease  the  amount  of  gases  used. 

Physical  Properties. — Nitrous  oxid,  "laughing  gas,"  nitrogen  prot- 
oxid,  nitrogen  monoxid,  ISTgO,  is  a  colorless  gas  at  ordinary  tempera- 
tures; it  possesses  a  specific  gravity  of  1.527.  One  liter  of  the  gas 
weighs  1.97  gm. ;  100  cubic  inches  weigh  47.29  gm.  Under  a  pressure  of 
50  atmospheres  at  +  7°  C.  (+44.6°  F.)  or  30  atmospheres  at  0°  C, 
it  is  converted  into  a  colorless  mobile  liquid  having  a  density  of  0.937 
(at  0°  C.) ;  ^  the  liquid  has  the  lowest  refractive  index  of  all  liquids. 
The  ease  with  which  it  may  be  liquefied  is  taken  advantage  of  and  liquid 
nitrous  oxid  is  supplied  on  the  market  in  steel  cylinders  of  various 
capacities.  A  convenient  size  for  short  operations,  or  for  preliminary 
administration  to  produce  unconsciousness  before  the  use  of  ether  or 
chloroform,  is  a  small  tube  weighing  about  39  ounces  gross,  which  holds 
6  ounces  of  the  gas.  For  hospital  work  vanadium-steel  cylinders  holding 
200  to  250  gallons  of  the  gas  are  serviceable.^  Fifteen  ounces  of  the 
liquid  on  evaporation  yield  about  fifty  gallons  of  the  gas.  The  cylinders 
usually,  and  should  always,  have  a  statement  upon  an  attached  label 
indicating  the  weight  of  liquid  within.  By  remembering  that  an  ounce 
of  the  liquid  yields  about  three  and  one-third  gallons  of  the  gas,  at 
ordinary  room  temperature  and  pressure,  the  operator  can  readily  know 
the  amount  of  gas  at  his  disposal.  By  weighing  before  and  after  use 
each  time,  and  entering  the  difference  upon  the  label,  the  anesthetist 
always  knows  what  his  supply  is.  This  information  is  of  vital  impor- 
tance in  some  cases. 

Nitrous  oxid,  like  other  gases,  expands  when  heated.  The  gas  and 
liquid  within  the  cylinder  are  under  a  theoretical  pressure  of  at  least 
750  pounds  per  square  inch  even  below  room  temperature.  Often  the 
pressure  is  over  1,000  pounds  per  square  inch.  If  the  cylinders  are  sub- 
jected to  undue  heat,  the  pressure  may  become  so  great  as  to  burst  the 
cylinder,  producing  serious  consequences;  therefore,  any  unnecessary 
heating  of  the  cylinder  should  be  avoided.  Such  accidental  explosions 
have  occurred. 

The  boiling  point  of  nitrous  oxid  at  760  mm.  pressure  is  — 90°  C; 
the  freezing  point  is  — 102°  C.  If  the  liquid  is  allowed  to  escape  under 
atmospheric  pressure  through  a  small  orifice,  part  of  it  is  converted  into 
a  compact  snow,^  which  has  a  temperature  of  — 100°  C.  This  snow, 
along  with  some  ice  produced  from  the  moisture  of  the  air  by  the  low 

^Faraday,  1823. 

^  According  to  the  best  modern  practice,  vanadium-steel  cylinders  are  the 
safest,  for,  even  if  they  burst,  they  are  not  shattered,  but  simply  split  along 
the  seam. 

'  Wills :  "A  Modification  of  Thilorier  's  Method  for  Preparing  Solid  Carbon 
Dioxide,"  J.  Chem.  Soc,  12,  ii,  21. 


NITROUS   OXID  121 

temperature,  may  sometimes  choke  the  outlet  and  interfere  with  the 
regular  flow  of  the  gas.  This  difficulty  will  never  be  encountered  when 
small  amounts  of  the  gas  are  used,  if  the  simple  precaution  be  taken  to 
keep  the  outlet  well  above  the  level  of  the  liquid  within — in  short,  if  the 
gas  is  drawn  off  with  the  cylinder  in  a  vertical  position,  outlet  upward.^ 
When,  however,  the  gas  is  to  be  used  in  prolonged  cases  it  is  desirable 
to  heat  the  outlet. 

Liquid  nitrous  oxid  may  be  preserved  with  perfect  safety  for  an 
indefinite  time  in  steel  cylinders  provided  with  good  valves.  Some 
administrators  "  have  noted  differences  between  nitrous  oxid  which  had 
and  had  not  been  liquefied.  These  differences  undoubtedly  were  due  to 
the  admission  of  undetermined  and  variable  amounts  of  air  in  prepara- 
tion for  or  during  administration,  or  to  temperature  conditions  brought 
about  by  administering  the  gas  from  the  liquid  without  the  warming 
referred  to  above. ^ 

Nitrous  oxid  is  soluble  in  water,  volume  for  volume,  at  0°  C. ;  the 
solubility  diminishes  greatly  on  elevation  of  the  temperature  of  the 
water.  The  solution  seems  to  be  mainly  physical,  as  we  have  no  evidence 
of  chemical  union  between  the  nitrous  oxid  and  water  as  in  the  case  of 
carbon  dioxid  and  water,  beyond  the  formation  of  an  unstable  hydroxid, 
N2O6H2O,  at  0°  C.  The  gas  may  be  collected  over  warm  water.  It 
is  quite  soluble  in  absolute  alcohol  at  zero. 

Chemical  Properties. — Nitrous  oxid  is  quite  stable,  not  being  decom- 
posed into  its  elementary  constituents  by  heat,  unless  the  temperature  is 
very  high.  It  supports  combustion,  if  the  combustion  has  been  actively 
started;  that  is,  a  strongly  burning  taper  is  not  extinguished  when 
plunged  into  the  gas,  but  continues  to  burn,  utilizing  the  oxygen  and 
liberating  the  nitrogen.  Nitrous  oxid  has  a  pleasant  odor  and  a  slightly 
sweet  taste.  It  may  be  respired  without  discomfort,  with  suitable  ap- 
paratus.    When  pure  it  exhibits  no  irritant  properties. 

Impurities  of  Nitrous  Oxid. — The  manufacture  of  nitrous  oxid  de- 
pends upon  heating  ammonium  nitrate, 

NH,N03==N20+2H20;    or 
some  combination  of  salts  which  produces  ammonium  nitrate,  as,  for 
example,   KNOa  +  NH.Cl;     SNaNOg  +  (NHJ3PO,;     or    2NaN03  + 

^  In  connection  with  the  devices  for  using  cylinders  in  the  horizontal  position, 
see  Sheppard:     Lancet,  1891,  424;  Hewitt,  "Anaesthetics,"  3rd  ed.,  268. 

^Eoberts:     Brit.  J.  Dent.  Sci.,  Dee.  15,  1884. 

"Smith  and  Leman:  J.  Am.  Chem.  Soc,  1911,  33,  1116,  give  analytical 
results  indicating  a  difference  in  the  gas  when  drawn  from  cylinders  with  the 
outlet  upward  or  reversed.  They  state  that  there  is  less  nitrous  oxid  and  more 
air  (than  that  originally  in  the  cylinder)  in  the  gas  when  first  drawn  from 
the  upright  cylinders.  Cylinders  should  have  all  the  air  removed  before  filling. 
If  this  has  not  been  the  case  and  the  cylinder  is  thoroughly  shaken  just  before 
the  use,  the  gas  is  of  uniform  composition,  as  has  been,  shown  by  Baskerville. 


122 


ANESTHESIA 


(^114)2804.^  The  impurities  liable  to  be  present  depend  upon  the 
materials  used,  proportions  present,  heat  treatment,  and  conditions  of 
the  pumps  and  containers. ^ 

Compressed   nitrous  oxid  obtained   in  the   American  market  from 
different  manufacturers  gave  on  analysis  the  following  values: 


ANALYSIS* 


Sample 

No. 

N2O 

H2O 

CO2 

NH3 

O2 

N2,etc. 
bydiff. 

N20by 
explo- 
sion 

N2O  by 

Cu  + 
CO2+H2 

NsOby 

Cu  + 

H2 

1 

99.7 

0.13 

0 

0.006 

Present 

0.16 

97.5 

99.4 

99.7 

2 

96.6 

0.15 

0 

0.001 

Present 

3.25 

95.0 

96.2 

96.6 

3 

99.5 

0.15 

0 

0 

Present 

0.35 

97.3 

99.3 

99.5 

4 

95.9 

0.16 

Present 

0 

Present 

3.94 

94.1 

95.6 

95.9 

*  Baskerville   and  Stevenson,  loc  cit.     Tlie  last  column  gives  the  figures  con- 
tained by  the  new  method  devised  by  them. 


Smith  and  Leman  analyzed  four  cylinders  of  liquid  nitrous  oxid 
from  different  manufacturers,  with  the  results  shown  on  page  123.^ 

Standard  of  Purity. — Nitrous  oxid  which  is  to  be  used  for  anesthetic 
purposes  should  contain   at  least  95  per  cent  of  NgO   and  no  solids, 


*  One  of  the  authors  (C.  B.),  in  conjunction  with  Stevenson,  has  made  an 
investigation  of  this  subject  and  devised  methods  of  analysis,  for  the  details  of 
which  see  J.  Ind.  and  Eng.  Chem.,  Aug.,  1911.  Erdman  and  Stolzenberg,  Berlin, 
43,  1708,  Willard,  Compt.  rend.  (1894)  118,  646,  found  that  a  hydrate  of 
nitrous  oxid  (N2O.6H2O)  may  be  obtained  by  keeping  at  0°,  in  a  sealed  tube, 
a  mixture  of  liquid  nitrous  oxid  and  water.  Ice  does  not  appear  to  react  with 
nitrous  oxid.  Willard  {ibid.,  118,  1096)  found  that  nitrous  oxid  may  be  freed 
from  air  and  nitrogen,  the  commonest  contaminants,  according  to  him,  by  the 
preparation  of  this  hydrate,  which,  although  scarcely  decomposed  below  0°  under 
ordinary  pressure,  furnishes  about  200  times  its  volume  of  gas  when  warmed 
above  this  temperature.  He  devised  an  apparatus  for  the  purification  of  nitrous 
oxid  by  this  means.     [Ann.  Chim.  Phys.  (7),  11,  289.] 

^  Commercial  nitrous  oxid  is  apt  to  contain  these  impurities :  CI2,  No, 
NO2,  HNO3,  NH3,  HCl,  CO2,  O2,  Nj,  rare  gases  of  the  air,  and  organic  matter 
(from  lubricants).  Of  these  the  first  six  only  produce  any  irritation  of  the 
respiratory  mucous  membrane,  and  they  are  usually  removed  in  its  manufacture, 
if  present,  by  washing  the  gas  in  turn  with  solutions  of  sodium  hydroxid,  fer- 
rous sulphate,  and  sulphuric  acid.  Further  purification  may  be  accomplished 
by  the  formation  of  a  hydrate  below  0°  C,  by  fractional  condensation  and 
subsequent  fractional  distillation. 

V.  Am.  Med.  Assn.,  57,  No.  7. 


NITROUS   OXID 


123 


Percentage  of 


Nitrous  oxid  . 

Oxygen 

Nitrogen  .  .  .  . 
Carbon  dioxid 


No.  1 


95.4 
0.0 
4.6 
0.0 


No.  2 

No.  3 

93.4 

95.8 

1.4 

1.1 

5.2 

3.1 

0.0 

0.0 

No.  4 

96.1 
0.1 
3.5 
0.3 


liquids,  combustible  organic  matter,  chlorin,  or  other  oxids  of  nitrogen.  ^ 
The  last  two  impurities  may  be  tested  for  by  slowly  passing  10  liters 
through  silver  nitrate  and  ferrous  sulphate  solutions.  No  precipitate 
should  be  produced  in  the  former,  and  no  brown  or  black  coloration  in 
the  latter. 

SPECIAL   PHYSIOLOGY 


The  evolution  of  knowledge  concerning  the  physiological  action  of 
nitrous  oxid  administered  by  inhalation  is  striking  and  the  changes  of 
opinion  are  radical.  The  conceptions  of  the  physiological  action  of  this 
agent  have,  in  a  large  measure,  been  controlled  by  the  clinical  methods 
of  administration  employed  at  various  times.  Three  distinct  steps  in 
this  process  of  elimination  and  np-building,  based  upon  experimental 
and  clinical  data,  may  be  traced. 

The  Hyperoxygenation  Theory. — Sir  Humphrey  Davy  believed  that 
nitrous  oxid  was  decomposed  into  its  constituents,  nitrogen  and  oxy- 
gen, during  its  passage  through  the  circulation.  It  was  thought  that 
this  produced  superoxygenation  of  the  blood,  and  that  this  overproduc- 
tion of  oxygen  led  to  the  formation  of  unusual  amounts  of  carbon  dioxid, 
which,  in  turn,  produced  a  form  of  "internal  asphyxia." 

Oliver  and  Garrett  ^  examined  the  gases  of  the  blood  of  a  dog  while 
under  nitrous  oxid,  with  the  results  shown  on  page  124. 

From  these  figures  it  will  be  seen  that  there  is  undoubtedly  a  large 
increase  in  nitrogen  in  the  blood  after  nitrous  oxid  inhalation.  There 
seems,  however,  to  be  no  conclusive  evidence  that  nitrous  oxid  splits  up 
in  the  organism,  the  gas  being  too  stable  to  be  decomposed  at  the  tem- 
perature of  the  blood.     The  increase  in  nitrogen,  as  shown  by  the  fore- 

^  Lack  of  knowledge  of  the  content  of  real  ISTjO  may  seriously  interfere  with 
the  satisfactory  use  of  this,  the  safest,  anesthetic,  especially  when  it  is  admin- 
istered by  the  proper  method,  namely,  mixed  with  oxygen.  If  the  preparation 
contains  more  than  95  per  cent  NjO,  the  variation  in  the  proportion  of  the  two 
gases  will  depend  then,  in  fact,  upon  the  amount  of  oxygen  actually  mixed,  and 
the  percentage  is  not  seriously  altered. 

"^Lancet,  1893,  683.  (The  analytical  methods  and  technique  employed  in 
these   determinations  are  not  known.) 


124 


ANESTHESIA 


Normal 

Before 

After 

Dog 

Inhalation 

Inhalation 

qo, 

34.3 

15.66 

0, 

22.0 

3.49 

N, 

1.8 

11.23 

N2O 

22.49 

going  figures^,  remains  unexplained.  Frankland  ^  analyzed  the  expira- 
tory products  of  several  administrations  and  failed  to  find  any  distinct 
evidence  of  decomposition.  The  theory,  therefore,  that  the  brain  cells 
are  overpowered,  so  to  speak,  by  an  excess  of  oxygen,  with  the  resulting 
phenomenon  of  anesthesia,  was  abandoned  as  being  untenable. 

The  Deoxygenation  or  Asphyxiation  Theory. — When  it  became  fairly 
well  established  that  nitrous  oxid  is  too  stable  a  gas  to  be  decomposed 
upon  its  entrance  into  the  circulation,  as  formerly  supposed,  opinion 
swayed  in  the  opposite  direction,  and  the  theory  proposed  was  that,  the 
hemoglobin  of  the  blood  having  a  greater  affinity  for  nitrous  oxid  than 
for  oxygen  the  oxygen  becomes  displaced  from  the  lungs  and  other  tis- 
sues by  the  nitrous  oxid,  the  brain  cells  and  nervous  centers  being  thus 
starved,  so  far  as  oxygen  is  concerned,  are  smothered,  as  it  were,  by 
nitrous  oxid.  To  this  condition  the  term  asphyxiation  is  applied,  and 
unconsciousness,  or  anesthesia,  is  the  inevitable  result.  This  mechanical 
displacement  of  oxygen  by  nitrous  oxid,  leading  to  "tissue  asphyxia,'^ 
has  been  characterized  as  a  more  dangerous  view,  from  a  practical  stand- 
point, than  the  hyperoxygenation  theory. 

Hermann  ^  concluded  that  nitrous  oxid  was  simply  absorbed  by  the 
blood  plasma,  and  that  its  action  was  only  that  of  asphyxiation,  the  con- 
ditions being  accounted  for  by  the  exclusion  of  the  oxygen  normally 
breathed.  He  found  that  one  hundred  volumes  of  blood  at  body  tem- 
perature would  absorb  sixty  volumes  of  nitrous  oxid.  This  ratio  was 
later  fixed  by  Bert  as  one  hundred  to  forty-five. 

This  theory  of  so-called  deoxygenation  has  been  supported  by  Jolyet, 
Blance,  Duret,  Johnson,  Eeid,  Amory,  Wood,  Cerna,  and  many  others, 
and  lately  by  Crile. 

This  theory  held  sway,  as  did  the  short-lived  preceding  hyperoxy- 
genation theory,  during  the  period  when  nitrous  oxid  was  used  almost 
exclusively  for  dental  and  very  short  surgical  operations.  During  this 
time  nitrous  oxid  was  rarely  inhaled  pure.  It  was  not  only  difficult  to 
obtain  a  pure  gas,  but,  when  obtained,  it  was  administered  in  such  a  way 
that  it  was  variably  diluted  with  air,  the  effects  produced  being,  as  a 

^ St.  Bartholomew's  Hospital  Becord  V. 
"Brit.  Med.  J.,  1868,  378. 


NITROUS   OXID  125 

rule,  those  of  intoxication  rather  than  anesthesia.  Inasmuch  as  air 
exclusion,  or  oxygen  exclusion,  was  considered  the  prime  factor,  the 
apparatus  devised  during  that  period  aimed  at  this  object.  The  appara- 
tus devised  by  Colton  was  fitted  with  inspiratory  and  expiratory  valves 
for  the  purpose  of  accomplishing  the  rigid  exclusion  of  air. 

The  Theory  of  the  Specific  Action  of  Nitrous  Oxid  upon  the  Brain 
Cells. — Despite  the  fact  that  air-exclusion  was  aimed  at,  it  was  soon 
found  that  the  alternate  inhalation  of  nitrous  oxid  and  air  served  to 
maintain  a  more  or  less  complete  anesthesia  for  protracted  surgical 
operations.  The  asphyxiation  theory  was  generally  accepted  until  An- 
drews,^ in  1868  (see  History,  p.  34),  showed  that  anesthesia  could  be 
maintained  over  a  longer  or  shorter  time  at  will,  by  mixing  oxygen  with 
nitrous  oxid.  This,  quite  naturally,  upset  the  deoxygenation  theory, 
and  led  to  the  conclusion  that  the  nitrous  oxid  must  exercise  some 
specific  action  upon  the  train  cells..  The  observations  of  Bert^  and  the 
early  experiments  of  Buxton  ^  verified  the  hypothesis  that  nitrous  oxid 
produced  narcosis  by  virtue  of  other  than  asphyxiating  qualities. 

This  theory  has  held  its  own  up  to  the  present  time,  the  variation  of 
opinion  bearing  reference  to  what  constitutes  the  specific  action  of 
nitrous  oxid  upon  the  nervous  centers. 

Kemp,*  following  a  series  of  experiments  begun  in  1890,  for  the  pur- 
pose of  determining  the  validity  or  invalidity  of  the  deoxygenation 
theory  of  nitrous  oxid  anesthesia,  as  the  result  of  fourteen  experiments, 
took  a  position  intermediate  between  those  who  hold  that  the  action  of 
nitrous  oxid  and  of  nitrogen  is  the  same,  and  those  who  hold  that 
nitrous  oxid  is  simply  an  indifferent  gas,  acting  like  nitrogen.  He 
found  that  the  difference  in  the  action  of  the  two  gases,  when  given  pure, 
was  so  masked  by  the  rapid  onset  of  asphyxia  that  any  wide-reaching 
generalizations  were  unsatisfactory.  Two  points,  however,  he  considered 
worthy  of  especial  notice:  (1)  That  anesthesia  was  induced  more 
quickly  with  nitrous  oxid  than  with  nitrogen;  (2)  that  the  muscular 
movements  which  always  supervene  upon  deprivation  of  oxygen  were 
milder  with  nitrous  oxid  than  with  nitrogen. 

A  second  set  of  experiments  was  conducted  by  Kemp,  in  which 
enough  oxygen  was  given  to  sustain  the  life  of  the  animal  while  the 
action  of  nitrous  oxid  and  of  nitrogen  was  being  studied. 

These  experiments  lead  up  to  the  present-day  methods  of  administer- 
ing nitrous  oxid,  and  to  the  modification  of  the  physiological  action  of 

^Andrews:     J.  Brit.  Bent.  Sci.,  1869,  22. 

2  Bert :      ' '  Pression  iDaroraetrique. ' ' 

*  Buxton,  Dudley  W. :  (1)  "On  the  Physiological  Action  of  Nitrous  Oxide," 
Trans,  Odontological  Soc.  of  Great  Brit.,  1886,  n.  s.,  18,  133;  (2)  IMd.,  1887, 
n.  s.,  19,  90. 

*Kemp,  G.  T. :  "Nitrous  Oxide  Anesthesia,"  Brit  Med.  J.,  Nor.  20,  1897, 
1480. 


126  ANESTHESIA 

this  and  other  iuhalation  anesthetic  agents  by  oxygen,  as  detailed  in  the 
chapter  on  General  Physiology,  p.  30. 

In  the  following  discussion  of  the  action  of  nitrous  oxid  upon  the 
organism  it  is  to  be  borne  in  mind  that  the  gas,  given  alone,  is  under 
consideration.  It  is  especially  to  be  remembered,  however,  that  the 
administration  of  nitrous  oxid  alone  belongs  to  the  past  and  not  to  the 
present  period  of  the  science  of  the  administration  of  anesthetics. 

Brunn,^  who  discusses  the  mode  of  action  of  nitrous  oxid,  recalls  the 
demonstration  by  Bert  of  a  specific  narcotic  efficiency  on  the  part  of 
nitrous  oxid.  Bert  successfully  avoided  the  onset  of  asphyxia  by  means 
of  the  inhalation  of  the  nitrous  oxid-oxygen  mixture  under  pressure, 
proving  at  the  same  time  that  the  narcosis  could  be  arbitrarily  length- 
ened. In  this  way  he  demonstrated  the  accuracy  of  his  theoretical  reflec- 
tion, that  it  is  the  over-low  partial  pressure  of  the  nitrous  oxid — in  the 
nitrous  oxid  and  oxygen  mixture  as  inhaled  under  ordinary  atmospheric 
pressure — which  prevents  a  sufficient  absorption  of  nitrous  oxid  in  the 
blood  for  the  onset  of  narcosis.  This  deficit  was  successfully  remedied 
by  Bert  through  raising  this  partial  pressure  to  the  level  of  the  atmos- 
pheric pressure. 

Brunn  emphasizes  the  fact  that  in  order  to  understand  the  mode  of 
action  of  nitrous  oxid  it  is  necessary  to  keep  carefully  apart  the  experi- 
ments with  the  inhalation  of  pure  nitrous  oxid — which  always  involves 
two  factors,  namely,  the  nitrous  oxid  action  and  the  asphyxiation — 
and  the  experiments  with  the  inhalation  of  nitrous  oxid  under  a  simul- 
taneous supply  of  a  sufficient  quantity  of  oxygen. 

Brunn  refers  to  a  series  of  fundamental  experiments  which  were  made 
by  Goldstein,^  who  showed  the  narcotic  effect  of  nitrous  oxid  on  frogs. 
In  comparative  experiments,  a  frog  ceased  to  react  after  five  and  a  half 
minutes  to  strong  external  stimuli,  in  a  nitrous  oxid  atmosphere, 
whereas  the  same  frog  had  not  yet  lost  its  power  of  reaction  after  an 
hour  and  a  quarter  in  a  pure  hydrogen  atmosphere.  However,  the 
nitrous  oxid  narcosis  was  made  to  disappear  again  by  the  admixture  of 
a  small  quantity  of  air. 

For  the  explanation  of  this  phenomenon,  Goldstein  regarded  the 
assumption  of  diminished  partial  pressure  as  insufficient,  and  he 
believed,  in  contradistinction  to  Bert's  views,  that  a  rapid  and  complete 
narcosis  was  produced  and  maintained  only  when  the  effect  of  the 
nitrous  oxid  was  combined  witli  that  of  a  deficiency  in  oxygen.  This 
statement  certainly  holds  good  for  "ordinary"  nitrous  oxid  anesthesia, 
but  he  admitted  himself  that  in  a  greater  density  of  the  nitrous  oxid 
this  was  alone  sufficient  for  the  production  of  a  complete  narcosis. 

^  Brunn,  M.  v. :  "  Die  Stickoxydulnarkose, "  "  Die  allgemein  Narkose, ' ' 
1913,   325. 

-Brunn;     Die  allgemein  Narkose, "  1913,  325  et  seq. 


NITROUS    OXID  127 

The  study  of  the  respiration  of  warm-blooded  animals,  under  the 
effect  of  nitrous  oxid,  first  led  Goldstein  to  recognize  the  fact  that  in 
rabbits  the  respiration  gradually  becomes  slower  and  more  superficial, 
in  an  inclosed  space  with  air  as  well  as  in  a  mixture  of  nitrous  oxid 
and  oxygej^,,  until  the  respiration  finally  ceases,  at  3-4  per  cent  oxygen 
contents  of  the  gas  mixture,  without  preceding  signs  of  dyspnea.  In 
sudden  asphyxiation  Goldstein  distinguished  three  stages.  The  first  is 
characterized  by  inspiratory  efforts,  to  which  are  added,  in  the  second 
stage,  violent  expiratory  muscular  efforts,  corhbined  with  clonic  convul- 
sions; in  the  third  stage  there  are  infrequent  inspiratory  movements, 
the  expiratory  muscles  remaining  entirely  inactive.  Comparative  experi- 
ments, with  inhalation  of  nitrogen  on  the  one  hand  and  nitrous  oxid 
on  the  other,  yielded  considerable  differences.  In  the  case  of  nitrous 
oxid,  narcotic  effects  are  almost  instantaneously  manifested,  so  that  the 
dyspneic  efforts  do  not  reach  nearly  the  same  degree  as  in  breathing 
nitrogen.  The  clonic  convulsions  are  altogether  absent.  The  second 
stage  of  the  asphyxiation  is  more  rapidly  terminated.  The  most  impor- 
tant difference,  however,  as  compared  to  ordinary  asphyxiation,  accord- 
ing to  Goldstein,  is  the  appearance  of  loss  of  reflexes  only  just  before 
the  respiratory  paralysis,  namely,  in  the  second  half  of  the  third  stage 
of  asphyxiation  in  ordinary  asphyxiation;  whereas,  in  nitrous  oxid 
inhalation,  the  loss  of  reflexes  is  already  present  in  the  second  stage, 
namely,  long  before  the  respiratory  center  is  endangered. 

In  Goldstein's  experience  the  inhalation  of  a  mixture  of  73  per  cent 
nitrous  oxid  and  27  per  cent  oxygen,  in  dogs,  was  followed  by  a  diminu- 
tion in  the  number  of  respirations,  while  the  depth  was  increased.  The 
anesthesia,  according  to  Goldstein,  appears  the  more  rapidly,  and  with  a 
proportionately  less  degree  of  asphyxia,  the  higher  the  organization  of 
the  brain — namely,  earlier  in  man  than  in  the  laboratory  animals. 

Effects  upon  the  Respiratory  System. — Experimental  observations 
have  established  the  fact  that  nitrous  oxid,  given  pure,  or  alone,  rapidly 
induces  asphyxia  by  gradual  paralysis  of  the  respiratory  center  in  con- 
sequence of  the  prolonged  action  of  the  increasingly  deoxygenated,  or 
venous,  blood.  The  respirations,  which  at  first  become  more  rapid  and 
deep,  become  convulsive  as  the  deoxygenation  process  is  continued,  then 
slow  and  shallow,  finally  ceasing  altogether.  When  the  asphyxial  ele- 
ment is  absent,  the  convulsive  character  of  the  respirations  is  not  noted. 

Numerous  experiments  with  animals  have  established  the  fact  that 
when  death  is  caused  by  pure  nitrous  oxid  the  usual  post  mortem  signs 
of  asphyxia  are  present.  It  has  been  emphasized  by  Hewitt  ^  that  the 
character  of  the  pulse  is  greatly  dependent  upon  the  fullness  and  efii- 
ciency  of  the  respiration.  Whatever  differences  there  may  be  between 
the  phenomena  produced  by  nitrous  oxid,  by  nitrogen,  and  by  mechan- 

^ Hewitt:     "Anaesthetics,"  1912,  90. 


128  ANESTHESIA 

ical  closure  of  the  trachea,  one  and  all,  according  to  Hewitt,  lead  to 
fatal  asphyxia. 

Because  of  the  lessened  amount  of  tissue  change  which  takes  place 
in  nitrous  oxid  anesthesia,  the  quantity  of  carbon  dioxid  given  off  by 
the  lungs  is.  decreased.  The  significance  of  this,  with  reference  to  the 
practical  question  of  shock,  is  considered  in  the  Chapter  on  Treatment 
Before,  During,  and  After  Anesthesia. 

JSTitrous  oxid  is  not  injurious  to  the  lungs,  being  a  non-irritating 
gas.  The  bronchial  irritation  of  which  some  have  complained  is  par- 
tially eliminated  by  warming  the  agent  (see  Chapter  on  General  Phys- 
iology, p.  64).  It  is  still  further  eliminated  by  passing  the  gases 
through  water,  as  described  on  page  323. 

For  men,  Goldstein  ^  emphasizes  the  point  that  anesthesia  sufficing 
for  the  performance  of  brief  operations  is  already  present  prior  to  the 
extinction  of  the  reflexes,  at  a  time  when  the  respiration  is  regular, 
deep,  and  of  almost  normal  frequency.  The  pulse  at  this  time  is  also 
approximately  normal  and  of  increased  volume. 

Effects  upon  the  Circulatory  System. — There  is  a  divergence  of  opin- 
ion concerning  the  actual  role  played  by  nitrous  oxid  in  the  Mood. 
According  to  Buxton's  ^  view,  nitrous  oxid,  when  administered  pure, 
enters  the  blood  by  diffusing  through  the  thin  walls  of  the  air-cells  in 
the  lungs.  A  small  quantity  is  dissolved  in  the  blood,  but  the  bulk  of 
the  gas  is  connected  in  some  loose  way  with  the  constituents  of  the 
blood.  Buxton's  view  is  that  it  is  probably  associated  moi-e  or  less 
closely  with  the  albumins  and  albuminoids  of  the  liquor  sanguinis  and 
corpuscles.  He  does  not  think  that  there  is  any  destruction  of  red  blood 
corpuscles.  He  reports  having  carefully  watched  the  corpuscles  in  the 
web  of  a  frog's  foot  while  the  frog  was  in  a  bell- jar  of  nitrous  oxid,  and 
was  able  to  observe  not  only  the  phenomena  of  the  circulation  under 
these  conditions,  but  also  to  satisfy  himself  that  no  breaking  up  of 
corpuscles  was  evident.  The  loose  association  which  nitrous  oxid  is 
assumed  to  form  with  hemoglobin,  as  proved  by  the  darkened  color  taken 
on  by  arterial  blood  when  it  is  shaken  with  the  gas,  seems  to  indicate 
that  nitrous  oxid  is  able  to  displace  oxygen  in  its  chemical  union  in  the 
blood.  This  combination  of  nitrous  oxid  with  the  constituents  of  the 
blood,  if  such  actually  occurs,  is  very  unstable  and  very  different  from 
that  produced  by  carbon  monoxid,  which  is  cumulative.  Blood  which 
has  been  saturated  with  nitrous  oxid  gives  it  up  at  once  when  left  in  free 
contact  with  oxygen  or  the  air,  and  this  has  been  used  as  a  strong  argu- 
ment against  the  acceptance  of  the  formation  of  a  compound,  however 
loose  it  might  be.  This  does  not  necessarily  follow,  for  such  conduct 
may  readily  be  due  to  mass  action,  that  is  to  say,  both  oxygen  and 

*  Brunn :   Loc.  cit. 

'■"  Buxton  :      ' '  Ansestheties, ' '    1907,   60. 


NITROUS   OXID  129 

nitrous  ox  id  may  form  weak  compounds  with  hemoglobin,  the  former 
being  the  stronger.  Fresh  hemoglobin  will  form  compounds  with  the 
respective  gases  in  proportion,  not  only  in  accord  with  the  stability  of 
the  compounds,  but  in  proportion  to  the  relative  quantities  brought  in 
contact  with  the  hemoglobin.  When  the  percentage  of  nitrogen  mon- 
oxid  in  inspired  air  is  very  small  it  forms  practically  no  appreciable 
amount  of  its  loose  compound,  at  least  not  a  sufficient  quantity  to  circu- 
late in  the  system  to  produce  its  physiological  effects  beyond  those  of 
exhilaration,  i.  e.,  intoxication.  When  the  inspired  gas  contains  only 
nitrous  oxid  the  percentage  will  be  rapidly  diminished;  in  fact,  almost 
as  fast  as  the  oxyhemoglobin  in  the  blood  is  brought  in  contact  with 
it.  By  regulating  the  proportions  of  the  two  gases  brought  into  con- 
tact with  the  blood,  it  is  theoretically  possible  to  keep  the  oxygenation 
of  the  tissues  going  on  as  in  normal  life  and  at  the  same  time  secure  the 
true  physiological  effect  of  the  nitrous  oxid.  In  maintaining  these  con- 
ditions another  important  factor  enters  in,  namely,  carbon  dioxid. 
Yandell  Henderson  ^  has  demonstrated  that  the  carbon  dioxid  in  the 
blood  is  a  respiratory  stimulant.  Therefore,  overventilation  with  oxygen 
is  to  be  avoided.  In  advocating  rebreathing  of  nitrous  oxid-oxygen 
mixture,  Gatch  ^  claims  that  the  beneficial  effects  are  due  to  the  carbon 
dioxid  which  comes  from  the  expired  air.  His  practice  is  to  allow 
rebreathing  until  the  percentage  of  carbon  dioxid  in  the  gas  in  the  bag 
reaches  four  per  cent;  that  is  to  say,  the  composition  of  ordinary  expired 
air  as  far  as  carbon  dioxid  is  concerned.  For  a  more  detailed  treatment 
of  this  the  reader  is  referred  to  the  Chapter  on  Eebreathing. 

If  the  absorption  is  a  phenomenon  of  simple  solution — and  that 
nitrous  oxid  displaces  a  certain  amount  of  oxygen  in  the  blood  is  gen- 
erally accepted  by  all  observers — then  the  amount  actually  absorbed  by 
the  blood  will  depend  upon  the  percentage  composition  of  the  mixed 
gases  inhaled;  that  is,  the  partial  pressure  exerted  by  the  gas  in  ques- 
tion. When  nitrous  oxid  containing  practically  no  free  oxygen  is 
inhaled  the  normal  oxygen  content  of  the  blood  is  quickly  diminished. 
If  the  percentage  of  nitrous  oxid  in  the  inspired  gases  is  reduced  to 
the  minimum  by  discontinuing  its  administration,  that  which  was  ab- 
sorbed is  quickly  thrown  out  of  the  circulation  by  virtue  of  its  vapor 
tension  and  oxygen  takes  its  place,  reproducing  the  normal  conditions 
of  the  gaseous  contents  of  the  blood,  as  far  as  oxygen ,  is  concerned. 

In  the  blood,  according  to  the  investigations  of  Klikowisch,^  nitrous 
oxid  causes  no  chemical  or  morphological  changes  of  any  kind,  but  it  is 

' ' '  Acapnia  and  Shock, "  "  Carbon  Dioxide  as  a  Factor  in  the  Eegulation  of 
the  Heart  Eate, ' '  Am.  J.  Physiol,  Feb.  1,  1908,  SI,  No.  1. 

^"Nitrous  Oxide-Oxygen  Anesthesia  by  the  Method  of  Eebreathing,"  /.  Am. 
Med.  Assn.,  March  5,  3910. 

'  Brunn :     Loc.  cit. 


130  ANESTHESIA 

in  the  blood  merely  in  the  form  of  a  physical  solution.  It  is  pro- 
portionately rapidly  reexcreted  on  diminution  of  the  partial  pressure. 
Decomposition  of  the  nitrous  oxid  in  the  blood  into  oxygen  and  nitrogen 
does  not  seem  to  occur.  In  the  spectral  analysis  the  behavior  of  blood 
that  has  been  saturated  with  nitrous  oxid  is  the  same  as  that  of  blood 
containing  oxyhemoglobin  (Klikowisch;,  Eothmann).  This  also  goes 
to  show  that  nitrous  oxid  does  not  enter  into  any  stable  chemical  com- 
bination with  oxyhemoglobin.  Besides  the  short  duration  of  the  nar- 
cosis, the  absence  of  after-effects  likewise  points  in  the  same  direction. 
The  opposite  view  of  Ulbrich  is  declined  by  Eothmann,  who  explains  the 
divergent  findings  of  Ulbrich  as  due  to  the  employment  of  too  highly 
concentrated  blood  solutions,  causing  the  absorption  bands  to  become 
wider  and  less  distinct. 

Eeeently  (1908)  Hamburger  and  Ewing  have  expressed  themselves 
in  favor  of  the  harmlessness  of  nitrous  oxid  for  the  blood.  They  found 
it  to  produce  no  permanent  diminution  of  the  hemoglobin,  and  no 
anemia,  as  well  as  no  increased  hemolysis.  Although  differences  in  the 
quantity  of  the  hemoglobin  and  the  red  blood  corpuscles  may  occur,  they 
are  of  transitory  character  and  devoid  of  surgical  importance.  The 
formation  of  reduced  hemoglobin  is  not  referable  to  the  anesthetic,  but 
to  the  associated  asphyxia.  An  increase  of  the  time  of  coagulation  is 
common,  but  not  invariably  present. 

The  experiments  of  Buxton  ^  and  later  of  Wood  and  Cerna  ^  indicate 
that  nitrous  oxid  exerts  a  direct  action  upon  the  heart  itself,  having 
little  or  no  direct  influence  upon  the  vasomotor  centers  of  the  brain 
cortex.  Kemp,'^  on  the  other  hand,  holds  that  nitrous  oxid  can  hardly 
be  said  to  exert  a  direct  action  upon  the  heart,  the  cardiac  effects  being 
much  more  apt  to  depend  upon  the  amount  of  oxygen  admitted  than 
upon  the  nitrous  oxid.  For  further  data  concerning  the  modification 
of  the  anesthetic  by  oxygen  or  by  atmospheric  air,  see  Chapter  II, 
General  Physiology. 

Blood  pressure  is  always  increased  with  nitrous  oxid  given  alone. 
With  a  judicious  use  of  air  or  oxygen  nitrous  oxid  anesthesia  may  be 
continued  for  a  sufficient  time  to  permit  of  any  ordinary  surgical  inter- 
vention with  very  little  variation  in  blood  pressure. 

Concerning  the  blood  pressure,  Goldstein's  *  findings  showed  a 
marked  increase  to  be  exceptional,  in  contradistinction  to  the  usual  belief 
that  blood  pressure  rapidly  undergoes  an  enormous  increase  in  the  first 
stages  of  the  asphyxiation.  His  first  experiments  concerned  asphyxia- 
tions  with  nitrogen  and  hydrogen,  but  a  considerable  rise  of  the  blood 

^"AnEBsthetics,"  1907,  57  et  seq. 
"Therap.  Gas.,  Aug.,  1890. 
^Brit.  Med.  J.,  Nov.  20,  1897,  1482. 
*  Brunn :      Loc.   cit. 


NITROUS    OXID  131 

pressure  was  likewise  absent  with  nitrous  oxid,  although  some  increase 
was  present.  The  blood  pressure  underwent  no  essential  changes  when 
dogs  and  rabbits  were  given,  in  addition  to  the  nitrous  oxid,  a  quantity 
of  air  sufficient  for  the  avoidance  of  dyspnea. 

Effects  Upon  the  Nervous  System. — It  has  already  been  noted  that 
the  third  distinct  step  in  the  evolution  of  knowledge  concerning  the 
physiological  action  of  nitrous  oxid  had  for  its  foundation  the  specific 
action  of  the  agent  upon  the  nervous  system.  The  earlier  experiments 
of  Buxton,  Wood  and  Cerna,  and  others,  to  which  reference  has  already 
been  made,  confirmed  the  theory  of  the  direct  action  of  the  gas  upon  the 
nervous  system.  Buxton,^  in  observations  upon  this  subject,  found  that, 
while  asphyxia  caused  diminution  of  the  bulk  of  the  brain  and  cord, 
nitrous  oxid  produced  so  great  an  enlargement  as  to  force  out  the 
cerebrospinal  fluid.  He  referred  these  changes  to  a  vasomotor  origin, 
and  held  that  they  explained  many  of  the  nervous  phenomena  elicited  in 
persons  narcotized  with  nitrous  oxid.  The  most  natural  inference,  from 
the  study  of  the  reflexes  and  other  effects  upon  the  nervous  system,  is, 
according  to  Kemp,^  that  nitrous  oxid  acts  most  powerfully  upon  the 
central  nervous  system,  especially  upon  the  brain  cortex. 

The  effect  of  nitrous  oxid,  when  first  inhaled,  is  a  pleasurable  exhil- 
aration, which  varies  with  the  individual,  with  the  degree  of  dilution  of 
the  gas  with  oxygen  or  air,  and  with  the  method  of  administration 
employed.  During  this  time  the  senses  of  the  individual  are  rendered 
more  acute ;  this  is  followed  by  analgesia ;  and  then  by  anesthesia,  during 
which  last  the  patient  is  profoundly  unconscious  and  insensitive  to 
pain. 

Hallucinations,  frequently  of  an  erotic  nature,  often  mark  the  hyper- 
esthetic  stage  which  precedes  anesthesia.  These  not  infrequently  persist 
after  the  complete  return  of  consciousness.  The  practical  and  medico- 
legal significance  of  this  phase  of  nitrous  oxid  anesthesia  is  easily 
apparent. 

Effects  Upon  the  Muscular  System. — It  is  a  well-established  fact  that 
nitrous  oxid  does  not  usually  induce  muscular  relaxation  when  adminis- 
tered alone.  When  oxygen  deprivation  is  complete,  and  the  administra- 
tion of  nitrous  oxid  is  continued,  the  limbs  become  rigid,  the  body  some- 
times assuming  the  position  of  opisthotonos.  Sometimes  rhythmic 
tremors  of  the  upper  extremities  are  noted.  The  muscular  manifesta- 
tions, other  than  general  rigidity,  are  now  seldom  seen  in  nitrous  oxid 
anesthesia,  for  the  reason  that  it  is  practically  never  given  alone,  even 
for  very  short  operations.  For  a  further  discussion  of  the  muscular 
phenomena  see  Stages  of  Anesthesia,  p.  59. 

Effects  Upon  the  Glandular  System  and  Other  Structures. — Nitrous 

1  Buxton:      " Ansesthetics, "   1907,  62. 
^Kemp:     Log.  cit. 


132  ANESTHESIA 

oxid  causes,  according  to  Kemp/  a  contraction  of  the  renal  vessels,  so 
that  urinary  secretion  is  rapidly  diminished.  Inasmuch  as  nitrous  oxid 
is  not  eliminated  through  the  kidneys  (see  Chapter  on  Physiology,  page 
60),  it  would  seem  fair  to  assume  that  the  gas  exerts  no  unfavorable 
effect  upon-  these  organs,  and  that  the  albuminuria  sometimes  reported 
is  due  to  other  causes.  Involuntary  micturition  may  occur  during 
nitrous  oxid  anesthesia. 

The  alimentary  tract  is  not  unfavorably  affected  by  nitrous  oxid 
unless  its  administration  is  pushed  to  an  unnecessary  degree.  In  such 
case  there  may  be  some  nausea^  vomiting,  and  even  involuntary  defeca- 
tion. 

The  untoward  symptoms  which  accompany  nitrous  oxid  anesthesia 
are  generally  ascribed  to  unnecessary  deoxygenation  rather  than  to  any 
irritant  or  other  quality  of  the  gas  itself. 

Causes  of  Death..- — When  nitrous  oxid  is  given  pure,  or  alone,  death 
is  always  due  to  oxygen  deprivation  or  asphyxia.  The  heart  continues 
to  beat  after  respiration  has  ceased,  which  proves  that  death  is  not  due 
to  failure  of  circulation.  (For  further  data  concerning  the  effects  of 
overdose,  Avhich  may  lead  to  shock  or  to  death,  see  Stages  of  Anesthesia, 
p.  59,  and  General  Physiology,  Chapter  II.) 

Stages  of  Anesthesia. — The  stages  of  anesthesia  when  nitrous  oxid  is 
used  alone  are  rarely  seen.  Attempts  have  been  made  to  separate  the 
phenomena  and  to  classify  them  under  distinct  stages,  but  this  is  impos- 
sible for  the  reason  that  it  takes  only  from  thirty  seconds  to  one  minute 
to  reach  full  surgical  anesthesia,  the  time  elapsing  between  consciousness 
and  surgical  anesthesia  being  so  short  that  these  different  degrees  cannot 
be  noted. 

Inasmuch  as  nitrous  oxid  is  now  so  seldom  given  alone,  but  rather 
with  air,  with  oxygen,  or  with  the  utilization  of  rebreathing,  so  that  the 
duration  of  the  anesthetic  period  can  be  prolonged  at  will,  it  is  possible 
to  note  definite  stages  Just  as  is  the  case  with  other  inhalation  anes- 
thetics. The  course  of  the  anesthesia  is  smooth  and  practically  feature- 
less, as  is  the  case  with  the  other  agents,  unless  there  is  faulty  technique 
somewhere.  A  leak  in  the  apparatus,  a  mask  that  does  not  fit  snugly, 
too  much  oxygen,  not  enough  nitrous  oxid,  neglect  of  preliminary  med- 
ication— any  one  or  a  combination  of  these  errors  of  technique  may 
convert  a  featureless  narcosis  into  one  marked  by  more  or  less  disagree- 
able complications.  Prom  experiments  upon  lower  animals  it  is  known 
that  too  much  oxygen  or  too  little  nitrous  oxid  may  act  as  an  overdose, 
with  the  same  phenomena  noted  with  an  overdose  of  ether  or  chloroform. 

The  iirst  stage  is  marked  by  a  subjective  feeling  of  warmth  in  the 
lips,  and  a  sort  of  numbness  in  the  limbs  and  other  parts  of  the  body, 
quickly  followed  by  a  feeling  of  exhilaration,  sometimes  described  as  a 

^Kemp:     N.  Y.  Med.  J.,  Nov.,  1899. 


NITROUS    OXID  133 

"thrilling."  This  may  be,  and  generally  is,  accompanied  by  the  impulse 
to  breathe  more  rapidly  and  more  deeply.  Tinnitus,  a  feeling  of  fullness 
in  the  head,  and  a  "smothering"  sensation,  if  the  nitrous  oxid  is 
"pushed"  too  rapidly,  precede  the  loss  of  consciousness.  Objectively,  it  is 
noted  that  the  respirations  are  quickened  and  deepened,  the  pulse  grows 
fuller,  and  blood  pressure  is  raised.  Twenty  to  thirty  seconds  is  the 
average  duration  of  this  stage,  which  may  be  said  to  end  with  the  dis- 
appearance of  coordination  and  consciousness. 

The  second  stage,  or  stage  of  excitem,ent,  is  initiated  with  the  loss  of 
consciousness.  Incoherent  thoughts  and  words  and  purposeless  muscular 
movements,  particularly  of  the  arms  and  legs,  are  now  apt  to  occur. 
The  laughing,  crying,  muttering,  and  incoordinate  movements  vary  with 
the  patient.  As  may  be  imagined  from  the  name,  "laughing  gas,"  ex- 
hilaration rather  than  depression  is  apt  to  mark  the  psychic  phenomena 
of  this  stage.  It  is  during  this  period  that  fanciful,  sometimes  erotic, 
dreams,  which  may  persist  after  the  return  of  consciousness,  occur.  The 
pulse  is  still  full,  and  somewhat  more  rapid  than  during  the  first  stage. 
The  respirations  are  more  rapid  and  deeper  than  normal,  or  than  during 
the  first  stage  in  cases  where  the  right  proportion  of  air  or  oxygen  is  not 
given.  Swallowing  movements,  and  sometimes  stertor,  are  noted.  The 
pupils  become  dilated,  and  a  twitching  of  the  eyelids  is  often  followed 
by  their  separation.  The  skin  now  assumes  the  duskiness  or  lividity 
which  is  generally  a  feature  of  nitrous  oxid  anesthesia,  and  which  is 
more  or  less  marked  according  to  the  normal  complexion  of  the  indi- 
vidual and  according  to  the  care  with  which  the  administration  is  con- 
ducted. Hearing  continues  during  this  stage.  While  the  patient  is 
unconscious,  any  undue  roughness  or  careless  treatment  may  markedly 
increase  the  excitement,  aggravating  all  the  phenomena  noted.  No 
surgical  intervention  should  be  attempted  during  this  stage. 

The  third  stage,  or  the  stage  of  surgical  anesth  esia,  with  perfect  tech- 
nique, is  induced  in  about  sixty  seconds  to  four  minutes,  the  time  vary- 
ing, of  course,  with  the  patient,  with  the  purity  of  the  nitrous  oxid,  and 
with  the  technique  as  regards  the  regulation  of  oxygen  and  other  details. 
The  stertorous,  snoring  breathing,  with  loss  of  rhythm,  mentioned  by 
many  writers  as  marking  the  onset  of  the  surgical  stage  of  anesthesia, 
depends  upon  the  method  of  administration,  and  especially  upon  the  pre- 
liminary medication.  Breathing  should  be  automatic,  regular,  and  with- 
out noise.  The  pulse  is  full  and  regular,  and  slightly  increased  in  rapid- 
ity, from  80  to  90,  though  it  may  be  normal.  The  lividity  previously 
noted  should  not  be  increased  in  degree  as  anesthesia  advances.  The  lid 
and  other  reflexes  are  abolished,  and  muscular  relaxation  is  more  or  less 
complete,  according  to  the  purpose  of  the  anesthesia  and  the  technique 
employed. 

In  order  to  maintain  this  stage  of  surgical  anesthesia,  it  is  important 


134  ANESTHESIA 

not  to  give  too  much  ox3^gen  or  too  much  nitrous  oxid,  Avith  a  corre- 
sponding increase  or  decrease  of  the  other  gas.  The  time  required  to 
reach  this  stage  is  so  short  that  an  inexperienced  administrator  may 
allow  the  patient  to  "come  out"  or  to  go  on  to  the  stage  of  overdose.  In 
this  connection  it  is  to  be  borne  in  mind  that  nitrous  oxid  is  stimulat- 
ing, and  that  the  patient  must  not  be  allowed  to  return  to  the  second 
stage,  or  the  stage  of  hypersensitiveness. 

The  automatic  breathing,  with  or  without  stertor,  the  widely  dilated 
or  contracted  pupils  (varying  with  the  preliminary  medication),  full  and 
regular  pulse,  with  a  slight  degree  of  cyanosis,  indicate  the  third  stage. 
Two  or  three  stertorous  respirations  indicate  complete  anesthesia. 

The  fourth  stage,  or  stage  of  overdose,  supervenes  through  some  error 
of  technique  by  which  asphyxia  becomes  the  predominant  feature  of  the 
narcosis-.  Breathing  becomes  embarrassed,  usually  through  convulsive 
muscular  spasm.  The  interference  with  respiration  is  first  marked  by 
hyperpnea  (excessive  breathing),  then  by  dyspnea  (difficult  breathing). 
Violent  or  convulsive  expiratory  efforts,  sometimes  accompanied  by  gen- 
eral muscular  spasms,  mark  the  second  stage  of  asphyxia.  Following 
this  there  is  a  stage  of  exhaustion  in  which  muscular  spasm  is  super- 
seded by  muscular  flaccidity.  The  pupils  become  more  widely  dilated, 
the  lids  are  widely  open,  the  conjunctivae  are  insensitive,  the  pulse  be- 
comes imperceptible,  respiration  is  marked  by  prolonged  sighing  inspira- 
tions, which  gradually  cease.  Paralysis  of  the  respiratory  center  is  com- 
plete, and  death  supervenes.  Marked  cyanosis  accompanies  this  condi- 
tion of  affairs.  Interference  with  the  passage  of  the  blood  through  the 
pulmonary  and  systemic  vessels,  and  accumulation,  in  consequence,  of 
blood  in  the  right  side  of  the  heart  and  in  the  systemic  veins,  with  the 
circulation,  in  all  parts  of  the  body,  of  deoxygenated  blood,  explain  the 
eventuation  of  the  stage  of  overdose  in  nitrous  oxid  anesthesia. 

This  stage  of  anesthesia  may  be  rendered  more  liable  by  certain 
preexisting  conditions,  which  are  discussed  under  Contraindications. 
The  length  of  time  before  it  eventuates  in  death  varies  with  the  sub- 
ject. 

It  may  be  noted  that  the  time  required  to  reach  full  surgical  narcosis 
is  from  thirty  seconds  to  four  minutes,  varying  with  the  patient;  that 
the  available  period  for  operation  depends  entirely  upon  the  technique 
employed,  ranging  from  thirty  seconds  to  hours;  and  that  the  recovery 
period,  when  asphyxial  symptoms  do  not  occur,  is  completed  in  five  min- 
utes or  less  from  the  time  the  mask  is  removed. 

Elimination. — The  rapidity  with  which  the  blood  will  rid  itself  of 
nitrous  oxid  has  been  made  the  subject  of  study  by  Kemp,^  who  found, 
in  animal  experiments,  that  in  less  than  two  minutes  the  quantity  of 
nitrous  oxid  in  the  blood  fell  from  over  twenty  per  cent  to  six  and  nine- 

^Kemp:     Brit.  Med.  J.,  Nov.  20,  1897,  1480. 


NITROUS   OXID  135 

tenths  per  cent.  The  normal  rapid  recovery  of  patients,  he  holds,  is 
quite  in  accord  with  these  findings. 

It  has  already  been  noted  that  nitrous  oxid  is  not  eliminated  ])y  the 
kidneys.     The  lungs  furnish  the  channel  of  elimination  of  nitrous  oxid. 

After-Elf ects. — As  already  stated,  there  are  less  after-effects  with  this 
anesthetic  than  with  any  other.  The  only  possibility  of  after-effects  is 
when  the  subject  is  nnsuited  for  this  particular  form  of  anesthesia;  or 
when  an  irregular  narcosis  has  been  given ;  or  when  the  nervous  system 
is  so  upset  for  any  reason  that  the  least  excitement  is  cause  for  anxiety. 
The  Lancet  of  March,  1902,  mentions  a  case  in  which,  after  a  few  min- 
utes' inhalation,  the  patient  remained  practically  asleep  for  four  days. 
The  undesirable  patients  so  often  referred  to,  that  is,  men  with  powerful 
build,  are  sometimes  temporarily  unbalanced  after  a  short  administra- 
tion. Again,  those  with  weak  hearts  may  have  slight  pallor,  feebleness 
of  pulse,  and  faintness;  as  a  general  rule,  however,  all  of  these  things 
are  conspicuous  by  their  absence. 

COMPARISON    WITH    OTHER    AGENTS 

In  the  earlier  period  of  nitrous  oxid  history  this  agent  was  hardly 
comparable  with  other  inhalation  anesthetics,  inasmuch  as  it  was  not 
considered  a  true  anesthetic.  With  modern  methods,  however,  this  no 
longer  holds.  Nitrous  oxid  is  considered  as  truly  an  anesthetic  as  is 
ether  or  chloroform.  Given  with  oxygen  it  ranks  above  either  so  far  as 
safety  to  life  is  concerned.  In  point  of  after-effects  it  takes  precedence 
over  all  other  agents,  since  it  is  practically  free  from  sequelae  if  admin- 
istered with  a  fair  degree  of  care.  Nitrous  oxid  and  ether,  with  enough 
oxygen  to  prevent  cyanosis,  is  the  safest  inhalation  anesthetic,  both  as  to 
life  and  after-effects. 

INDICATIONS    AND    CONTRAINDICATIONS 

Nitrous  oxid  alone  is  very  limited  in  its  indications.  In  fact,  at  this 
stage  of  development  of  methods  of  administration  it  is  never  indicated. 
It  is  distinctly  contraindicated,  even  for  very  short  operations,  in  young 
children  (under  four  years),  because  of  their  immature  musculature, 
which  makes  breathing  in  the  bag  difficult  for  them.  It  is  also  distinctly 
contraindicated  with  old  persons,  or  persons  with  a  generally  weakened 
musculature,  and  in  adults  of  whatever  age  whose  arteries  are  sclerosed. 
Advanced  phthisis,  valvular  disease,  and  women  during  any  of  the  physi- 
ological epochs,  when  nervous  and  mental  phenomena  are  apt  to  be  easily 
exaggerated,  present  contraindications  to  the  use  of  nitrous  oxid  alone. 

When  this  gas  is  judiciously  employed,  with  the  careful  admission  of 


136  ANESTHESIA 

oxygen,  the  contraindications  are  modified.  It  is  still  contraindicated 
for  children,  because  these  patients  take  any  anesthetic  poorly  with  a 
closed  method.     (See  Chapter  VIII,  Selection  of  Anesthetic.) 

For-  strong,  muscular,  athletic,  alcoholic  and  obese  subjects,  or  per- 
sons with  any  obstruction  to  the  air  passages,  such  as  enlarged  tonsils, 
adenoids,  etc.,  and  for  ophthalmic  surgery,  nitrous  oxid  is  contraindi- 
cated, unless  employed  with  the  utmost  skill. 

ADMINISTRATION 

Before  discussing  the  different  methods  of  administration  it  might 
be  well  to  pause  and  consider  a  few  necessary  details. 

Heating  the  Gas. — This  is  accomplished  in  several  ways :  ( 1 )  by  an 
alcohol  lamp,  .with  a  coil  for  the  gas  going  through  the  upper  portion  of 
the  heater,  as  in  the  Teter  apparatus  (see  p.  152)  ;  (2)  by  a  coil  from 
the  tank  being  placed  in  a  hot  water  cup,  as  in  the  Gwathmey  anesthetizer 
(p.  150);  (3)  by  passing  the  gas  through  a  coil  contained  in  a  metal 
cylinder  filled  with  thermal  salts,  as  used  by  Griffith  Davis  (see 
p.  148)  ;  (4)  by  passing  the  gas  over  water  electrically  heated  (see 
p.  424). 

The  gas  should  be  heated  to  the  temperature  of  the  body.  Heating 
the  gas  admits  of  its  uniform  diffusion  through  the  alveolar  walls  and 
usually  enables  the  administrator  to  secure  surgical  anesthesia  before  the 
asphyxial  signs  occur. 

Essential  Features  of  Any  Satisfactory  Method  or  Apparatus. — All 
apparatus  should  embody  the  four  fundamental  principles  underlying 
the  successful  administration  of  nitrous  oxid  and  oxygen,  that  is  to  say, 
valvular  and  rebreathing,  warmed  vapors,  moisture  regulation  of  the 
pressure,  and  addition  of  other  anesthetics  when  needed. 

Apparatus  for  Administering  Nitrous  Oxid  Alone  or  with  Air. — All 
that  is  necessary  for  the  administration  of  the  gas  alone  is  a  tightly  fit- 
ting mask,  with  valves  which  may  be  thrown  out  of  use  when  rebreathing 
is  to  be  utilized.  To  this  mask  a  rubber  bag  is  attached.  Eubber  tubing 
connects  the  bag  with  the  gas  cylinder.  When  air  is  added  to  the  nitrous 
oxid  an  extra  valve  may  be  used  to  allow  definite  proportions  of  air. 

Dangers  of  Administration  of  Nitrous  Oxid  Alone. — The  majority 
of  fatalities  have  occurred  with  the  administration  of  nitrous  oxid 
alone,  and  given  through  valves.  Of  these  fatalities  the  greater  number 
were  men  in  robust  health  or  alcoholics.  Nitrous  oxid  has  no  toxic 
effect  as  have  chloroform  and  ether.  Death  occurs  as  a  result  of  asphyx- 
iation. 

The  only  possibility  of  a  death  by  asphyxiation  is  the  inability  of  the 
administrator  to  differentiate  between  asphyxial  and  anesthetic  signs. 
Whether  it  is  administered  alone,  with  air  or  with  oxygen,  the  anes- 


NITROUS   OXID  137 

thetist  should  be  careful  to  keep  a  clear  airway  and  see  that  no  asphyxial 
symptoms  occur  at  any  time. 

Recognition  of  Asphyxial  Symptoms. — Embarrassed  respiration,  ir- 
regular, shallow,  and  jerky,  is  an  asphyxial  symptom.  This  may  or  may 
not  be  accompanied  by  stertor.  The  fingers  and  muscles  of  the  arms  and 
legs  are  thrown  into  clonic  spasms,  which  quickly  develop  into  tonic 
spasms  with  rigidity  and  muscular  contraction  of  the  muscles  of  the 
neck  and  chest.  There  is  marked  cyanosis.  Eyelids  may  or  may  not  be 
closed,  but  are  usually  open  with  lid  reflex  present.  The  respiration 
ceases.  If  at  this  point  the  mask  is  removed,  in  the  vast  majority  of 
cases  the  patient  comes  out  of  this  state  apparently  none  the  worse  for 
the  experience.  The  heart  will  always  be  found  beating  slowly  and  regu- 
larly, even  after  cessation  of  respiration.  If,  however,  the  mask  is  held 
rigidly  in  place  at  this  point,  so  that  the  next  long,  deep  breath  is  gas 
instead  of  air,  a  cessation  of  all  the  vital  functions  is  apt  to  cease 
immediately.  No  administration  of  nitrous  oxid  should  be  attempted 
unless  the  anesthetist  is  prepared  for  a  tracheotomy. 

Administration  of  Nitrous  Oxid  Alone. — If  given  in  this  way,  with- 
out mixture  of  air  or  oxygen,  and  without  heating,  it  must  necessarily 
be  for  short  operations,  and  it  must  be  given  to  the  point  of  asphyxia- 
tion, then  discontinued  and  administered  again.  This  is  the  most  dan- 
gerous way  in  which  to  administer  the  gas,  and  should  never  be 
attempted  except  in  emergency  cases  or  as  a  sequence.  It  is  true  that 
patients  have  been  anesthetized  in  this  way  for  short  operations  with  a 
resulting  fatality  that  is  almost  negligible;  nevertheless,  90  per  cent  of 
all  fatalities  have  occurred  when  the  gas  was  thus  administered. 

Administration  to  Asphyxiation  with  and  without  Valves.: — A  crude 
method,  practiced  by  many  dentists,  is  to  administer  the  gas  to  the  point 
of  asphyxiation,  remove  the  mask,  and  make  the  extraction. 

Use  of  Expiratory  Valve  Alone. — Another  method  is  to  use  the  ex- 
piratory valve  alone,  thus  allowing  to-and-fro  breathing  from  the  first, 
and  increasing  the  pressure  until  full  anesthesia  ensues.  This  requires 
more  gas  and  a  little  longer  time,  but  it  is  almost  as  valuable  as  washing 
out  the  lungs  by  the  valvular  method,  and  then  switching  to  to-and-fro 
breathing.    It  is  preferable  to  using  valves  alone. 

Administration  without  Valves. — The  third  method  of  giving  the 
gas  is  without  any  valves,  by  allowing  the  gas  to  flow  in  the  mask  and 
simply  increasing  the  pressure  in  the  bag  and  allowing  the  surplus  to 
escape  under  the  margin  of  the  mask,  and  continuing  to  increase  the 
pressure  until  ingress  of  air  between  the  face  and  the  mask  is  impossible, 
and  full  anesthesia  is  secured.  This  is  a  makeshift,  and  a  wasteful 
method,  but  it  may  be  well  to  know  that  anesthesia  can  be  satisfactorily 
induced  in  an  emergency  in  this  way. 

Precautions  When  Administered  Alone. — Whenever  the  gas  is  ad- 


138 


ANESTHESIA 


ministered  alone,  as  for  the  extraction  of  a  tooth  or  the  opening  of  an 
abscess,  it  is  always  best  to  have  some  method  of  switching  from  the 
valves  to  to-and-fro  breathing.     With  some  patients  the  asphyxial  point 


Fig.  26. — Guedel's  Apparatus  for  the  Self-administration  of  Nitrous  Oxid  and 
Air.  Apparatus  attached  to  cylinder.  (1)  Stopcock  controlling  flow  of  gas  from 
supply  bag.  (2)  Respiratory  valve.  (For  detail  see  Fig.  27.)  (3)  Flexible  rubber  nose 
mask  without  valves.  Valves  are  removed  to  body  of  apparatus  so  that  mixture  of 
gas  and  air  can  be  regulated  without  disturbing  the  patient.  (4)  Metal  band  with 
hook  for  hanging  apparatus  to  operating  chair  or  table.  In  obstetrical  work  the  ap- 
paratus is  placed  on  its  side  on  the  bed.  (5)  Hollow  metal  handle  for  nose  mask. 
Patient  holds  mask. 


will  be  reached  before  true  anesthesia  occurs.  This  is  the  principal 
objection  to  the  administration  of  nitrous  oxid  alone.  When  adminis- 
tered only  part  of  the  time  through  valves,  the  anesthetist  should  make 
the  change  before  the  asphyxial  signs  occur,  and  deepen  the  anesthesia 


NITROUS   OXID 


139 


by  simply  holding  the  mask  in  position  and  allowing  the  patient  to 
breathe  back  and  forth  in  the  bag.  The  advantages  gained  by  this 
method  are  that  it  is  safer  and  also  gives  a  deeper  and  longer  period 
of  available  anesthesia  Vi^ith  a  smaller  amount  of  gas;  the  after-effect 
will  also  be  less.  In  fact,  by  closing  either  the  mouth  or  nares,  thus 
compelling  the  patient  to  breathe  through  the  one  open  airway,  and 
using  this  airway  for  the  administration,  a  satisfactory  anesthesia  has 
been  induced  by  inserting  the  rubber  tube  from  the  gas  tank  and  grad- 


3— — m^^^L 

I — jE^^y 

■ 

S^^HIflS^'  ' 

k.  '"  '  ' 

1   1 

\ 

ml 

Fig.  27. — Guedel's  Apparatus,  Showing  Detail  Construction  of  Respiratory 
Valve.  (1)  Expiratory  openings.  A  disc  prevents  the  entrance  of  air  during  in- 
spiration and  permits  the  escape  of  part  of  the  expired  gases  during  expiration.  (2)  In- 
spiratory openings  for  admitting  air  which  is  mixed  with  the  inspired  gas.  (3)  Screw 
for  regulating  percentages  of  inspired  air.  (4)  Screw  limiting  movements  of  disc  for 
regulating  amount  of  gas  rebreathed.  (5)  Graduated  dial  showing  percentages  of  air 
inspired. 


ually  increasing  the  pressure.  This  is  a  wasteful  method  and  is  not 
advocated.  In  all  cases  there  should  be  some  means  of  heating  the  gas 
before  it  reaches  the  patient. 

Guedel  has  perfected  an  apparatus  for  the  administration  of  nitrous 
oxid  alone,  and  especially  for  the  use  of  the  analgesic  stage  of  nitrous 
oxid.  He  recommends  it  specially  for  confinement  cases.  His  cylinder 
of  nitrous  oxid  is  placed  within  convenient  reach  of  the  patient.  The 
patient  takes  the  apparatus  and  places  it  over  the  nose  or  mouth  and 
inhales  until  the  anesthetic  stage  is  reached,  when  the  hands  drop  to  the 
side.     It  is  also  used  by  dentists  for  the  analgesic  stage  of  anesthesia. 


140  ANESTHESIA 

The  apparatus  is  commendable  in  that  it  is  very  simple  and  inexpensive. 
(See  Figs.  26  and  27.) 

Administration  of  Nitrous  Oxid  with  Air  in  Unknown  Quantities. — 
The  continuous  administration  of  nitrous  oxid  with  enough  air  to  pre- 
vent asphyxial  symptoms  places  a  severe  tax  upon  the  anesthetist's 
resources.  With  selected  subjects  and  under  proper  conditions  a  safe 
and  even  plane  of  anesthesia  can  be  maintained. 

Directions. —  (a)  With  valves  alone:  Place  the  mask  in  position 
and  induce  anesthesia  as  stated  above.  When  stertor,  irregular  breathing, 
or  automatic  breathing  announces  surgical  anesthesia,  raise  the  mask  for 
one  respiration,  then  reapply  and  hold  in  position  for  from  three  to  ten 
respirations,  according  to  the  patient,  when  another  breath  of  air  is 
given,  and  so  continued. 

(b)  With  valves  and  to-and-fro  breathing:  This  method  is  better 
for  the  patient,  keeping  the  pulse  nearly  normal,  respirations  deep  and 
full,  with  better  muscular  relaxation,  and  is  an  easier  anesthetic  to 
maintain.  In  getting  the  patient  under,  the  following  procedure  is 
usual : 

(1)  If  the  apparatus  will  allow,  have  the  patient  breathe  air  through 
the  valves  before  turning  on  the  gas. 

(2)  Turn  on  the  nitrous  oxid  and  allow  the  patient  to  breathe 
through  valves  from  three  to  seven  times. 

(3)  Now  have  to-and-fro  breathing  for  as  many  times. 

(4)  Eeturn  to  valves  for  three  to  seven  breaths. 

(5)  Now  have  to-and-fro  breathing  as  before. 

This  alternating  from  valves  to  to-and-fro  breathing  will  occupy  from 
forty  seconds  to  a  minute  and  a  half,  when  the  patient  will  be  found  to 
be  deeply  under  the  anesthetic. 

If,  now,  the  operation  is  to  last  for  one  hour  or  more,  either  the 
above  or  the  following  method  can  be  used  after  surgical  anesthesia  has 
been  established. 

Use  the  expiratory  valve  alone,  allowing  a  small  but  regular  flow  of 
the  gas  at  all  times,  thus  keeping  the  bag  fairly  distended  by  having 
rebreathing  constantly  and  removing  the  mask  whenever  the  stertor  or 
other  asphyxial  signs  become  too  marked.  This  method  is  especially 
useful  for  alcoholics  and  athletes,  and  all  other  patients  in  which  a  posi- 
tive pressure  is  indicated.  The  above  method  has  also  been  successfully 
employed  in  nose  and  throat  work,  using  the  nosepiece  with  expiratory 
valve  and  having  a  stopcock  between  the  nosepiece  and  bag  for  an  occa- 
sional breath  of  air.  By  regulating  the  expiratory  valve  any  amount  of 
pressure  can  be  maintained  in  the  lungs.  This  method  of  anesthesia  can 
be  kept  up  indefinitely,  and  is  especially  useful  in  adenoid  and  tonsil 
cases. 

This  rebreathing,  together  with  the  expiratory  valves,  can  be  more 


NITROUS   OXID  141 

readily  maintained  when  used  as  a  sequence  to  the  drop  method  of  etlicr 
(p.  204),  when  the  patient  has  been  under  the  influence  of  the  ether 
for  ten  to  fifteen  minutes,  or  toward  the  close  of  any  operation  lasting 
one  hour  or  more. 

The  Administration  of  Nitrous  Oxid  with  Definite  Amounts  of  Air. 
— Hewitt  has  made  a  number  of  experiments  to  determine  the  exa<;t  per- 
centage of  nitrous  oxid  suitable  to  be  administered  with  air.  The  fol- 
lowing are  the  net  results  of  these  experiments :  The  best  definite  mix- 
ture for  men  is  from  14  to  18  per  cent  of  air;  for  women  and  children, 
18  to  23  per  cent  of  air. 

If,  during  an  administration  of  nitrous  oxid  with  air,  the  supply 
of  oxygen  gives  out,  anesthesia  can  be  continued  by  pushing  back  the 
bag  containing  the  oxygen  so  that  air  can  be  admitted  through  the 
valve  and  allowing  a  continuous  flow  of  from  14  to  22  per  cent  of  air 
with  the  nitrous  oxid.  The  best  method  of  administration  is  for  the 
anesthetist  to  be  able  to  use  the  valves,  and  also  switch  to  to-and-fro 
breathing  at  any  time  during  the  administration.  Whenever,  for  any 
reason,  no  oxygen  is  at  hand,  it  is  necessary,  if  a  continuous  flow  of  air 
through  the  valves  is  to  be  allowed,  that  the  apparatus  is  so  arranged 
that  the  air  supply  is  independent  of  the  nitrous  oxid. 

Directions. — Anesthesia  is  instituted  as  follows:  Place  the  index 
to  the  air  valve  so  as  to  allow  an  intake  of  25  per  cent  of  air.  Allow 
the  full  intake  of  nitrous  oxid  through  that  valve.  After  two  or  three 
inspirations,  cut  down  the  air  intake  to  between  14  and  22  per  cent. 
Turn  the  nitrous  oxid  valve  so  as  to  allow  rebreathing  continuously. 
From  this  time  on  the  index  to  the  air  valve  must  be  changed  to  suit 
the  requirements  of  the  case.  If  positive  pressure  is  indicated,  this  can 
be  accomplished  by  tightening  the  screw  on  the  expiratory  valve  so  that 
very  little  air  escapes,  at  the  same  time  increasing  slightly  the  flow  of 
nitrous  oxid.  In  order  to  determine  approximately  the  percentage  of 
air  being  used,  the  flow  of  nitrous  oxid  must  be  an  even  one.  Occa- 
sionally it  will  be  necessary  to  cut  off  the  air  entirely  and  have  to-and-fro 
breathing  until  the  anesthesia  is  satisfactory;  then  return  to  the  valve 
and  continue.  This  form  of  anesthesia  is  especially  useful  as  a  sequence 
after  surgical  anesthesia  has  been  maintained  for  thirty  minutes  or  more, 
when,  for  any  reason,  the  chloroform  and  ether  should  be  reduced  to  a 
minimum. 

Nitrous  Oxid  as  a  Sequence  to  Ether. — Wlien  nitrous  oxid  is  used 
as  a  sequence  to  ether  the  reflexes  should  be  allowed  to  become  active 
before  instituting  the  change.  With  the  chloroform-ether-nitrous  oxid 
sequence  the  reflexes  should  be  very  active  and  the  change  be  made  grad- 
ually; that  is  to  say,  allow  rebreathing  in  the  bag  before  turning  on  the 
nitrous  oxid.  Even  in  laparotomies,  where  absolute  relaxation  is 
required,  after  anesthesia  lias  been  maintained  for  thirty  minutes  or 


142  ANESTHESIA 

more,  this  method  can  be  successfully  substituted.  This  reduces  the 
amount  of  ether  or  chloroform  to  a  minimum,  and,  there  being  less 
strain  upon  the  kidneys  and  lungs,  the  after-effects  are  reduced  to  a 
minimum. 

Nitrous  Oxid  with  Air. — As  previously  stated,  when  nitrous  oxid 
and  air  are  used  as  a  sequence,  the  maintenance  of  an  even  plane  of 
anesthesia  is  so  easy  and,  at  the  same  time,  satisfactory  that  the  descrip- 
tion of  the  technique  of  this  sequence  is  worthy  of  a  place  by  itself. 

Technique  of  Ether-Nitrous  Oxid  (Air)  Sequence. — If  ether  by  the 
drop  method  has  been  used  and  a  change  to  nitrous  oxid  is  desired, 
allow  the  reflexes  to  become  slightly  active;  place  the  mask  upon  the 
face  and  turn  to  to-and-fro  breathing,  the  bag  being  two-thirds  full  of 
the  nitrous  oxid.  Note  the  results,  and  increase  the  pressure  in  the 
bag  to  intensify  the  anesthesia,  or,  if  the  anesthesia  is  satisfactory,  main- 
tain it  by  either  of  the  methods  already  outlined.  When  the  reflexes  are 
abolished  slight  cyanosis  sets  in,  and  the  anesthesia  is  now  changed  to 
one  of  nitrous  oxid  and  air.  When  this  occurs  remove  the  mask  when- 
ever necessary  for  one  inhalation  or  more,  and  then  repeat,  allowing  the 
gas  to  flow  in  the  bag  slowly  but  regularly.  If,  however,  the  patient  is 
very  lightly  under,  allow  breathing  through  valves  for  three  to  eight 
respirations,  turn  to  to-and-fro  breathing,  then  allow  one  to  two  breaths 
of  air,  and  then  return  to  the  gas.  Allow  air  whenever  the  reflexes  are 
entirely  abolished  and  cyanosis  is  marked  and  breathing  stertorous. 

Technique  with  A.C.E. — The  technique  with  chloroform-ether,  or 
the  A.C.E.  mixture  is  as  follows : 

Allow  the  eyelids  and  other  reflexes  to  become  somewhat  active ;  place 
the  mask  upon  the  face  as  the  patient  exhales,  the  mask  being  arranged 
for  to-and-fro  breathing,  but  the  bag  empty.  Eemove  the  mask  from 
face,  allow  patient  one  breath  of  pure  air,  and  replace  mask  so  that  the 
exhalation  enters  the  bag.  Continue  thus,  alternately  raising  and 
replacing  the  mask  until  the  bag  is  filled.  When  this  occurs  hold  the 
mask  in  place.  If  reflexes  are  now  abolished  raise  the  mask  and  allow 
one  breath  of  air  and  thus  continue  until  reflexes  begin  to  get  quite  active 
again.  When  this  occurs  turn  on  gas  slowly,  alloAving  rebreathing  until 
they  are  lulled  or  abolished. 

Advantages  of  Ether-  (or  Chloroform-Ether)  Nitrous  Oxid  Se- 
quence.— By  instituting  nitrous  oxid  anesthesia  after  any  operation 
that  has  lasted  at  least  one  hour,  the  following  results  are  accomplished : 

A  non-poisonous  ^  anesthesia  replaces  a  poisonous  one  at  a  time  when 
a  stronger  anesthetic  is  capable  of  doing  the  greatest  damage.  The 
resisting  powers  of  any  individual  at  this  time  being  reduced  to  a  mini- 

^  The  term  non-poisonous  is  here  used  in  a  restricted  sense  as  compared  with 
chloroform  and  ether,  which  are  active  poisons  to  both  the  nerve  and  muacle 
fibers. 


NITROUS    OXID  143 

mum,  the  kidneys,  lungs,  and  otlior  parenchyma  are  thus  possihly 
saved  the  coup  de  grace.  Nitrous  oxid  and  air  fulfil  all  demands  at 
this  time,  the  relaxation  required  being  easily  maintained. 

The  Advantages  of  Administration  of  Oxygen  with  Nitrous  Oxid. — 
When  oxygen  is  used  with  nitrous  oxid,  a  safer,  deeper,  and  more  satis- 
factory anesthesia  is  obtained  than  is  possible  with  air.  When  the 
nitrous  oxid  is  heated  and  supplemented  by  warmed  moist  ether,  when 
necessary,  we  have  the  best  form  of  anesthesia,  considered  from  every 
standpoint,  available  to-day.  Those  who  have  never  used  oxygen  with 
nitrous  oxid,  and  who  have  acquired  the  technique  of  administering  it 
alone,  will  be  surprised  by  the  ease  and  latitude  given  by  this  combina- 
■  tion.  One  of  us  (J.  T.  G.)  has  given  several  anesthesias  lasting  for  two 
hours  and  more  with  nitrous  oxid  and  oxygen  without  the  aid  of  ether, 
chloroform,  or  ethyl  chlorid,  and  in  one  instance  the  anesthetic  was  not 
preceded  by  any  preliminary  medication.  With  adults  the  preliminary 
medication  gives  a  wider  latitude  to  the  anesthetist  than  if  this  were  not 
used.  When  the  subject  is  well  selected,  and  the  administration  properly 
conducted,  a  slight  increase  in  the  percentage  of  oxygen  being  allowed 
from  time  to  time  as  the  operation  proceeds,  the  mechanical  breathing, 
color,  and  reflexes,  together  with  the  relaxation  required,  are  sufficient 
guides  for  our  use.  The  pulse  and  respiration  will  usually  be  normal, 
except  when  stimulated  by  the  operation.  If  loud  stertor  commences  or 
increases  it  is  a  sign  for  more  oxygen.  If  muscular  twitches  are  observed 
at  any  time  this  also  is  an  indication  for  more  oxygen. 

In  anesthetizing  children  under  ten  years  of  age,  after  surgical  anes- 
thesia is  reached,  it  is  best  to  raise  the  mask  slightly  from  the  face,  about 
one-eighth  of  an  inch,  and  allow  the  little  patient  to  breathe  the  com- 
bined gases  by  having  a  plus  pressure  in  the  bag  at  all  times,  or  by 
keeping  the  expiratory  valve  open  and  allowing  rebreathing  constantly. 
Weak,  anemic  men  and  middle-aged  women  can  be  successfully  anes- 
thetized with  nitrous  oxid  and  oxygen  alone,  provided  the  valves  and 
rebreathing  are  used  discriminately.  With  a  vast  majority  of  patients 
it  is  safer  to  supplement  the  nitrous  oxid  and  oxygen  with  small 
amounts  of  ether. 

Superiority  of  Oxygen  Over  Air. — The  objection  to  using  air  is  that 
it  contains  a  large  percentage  of  nitrogen  which  is  useless  for  anesthetic 
purposes.  Hewitt  has  illustrated  this  in  the  following  manner :  When 
air  is  given  the  equation  could  read  like  this : 

..    ,,         ,        ,    ._  ^         S    8  per  cent  oxygen 

Air  (by  volume),  40  per  cent  =    i  r,,^  .     •, 

(62,  per  cent  nitrogen 

Nitrous  oxid         60  per  cent  =      60  per  cent  nitrous  oxid 

This  mixture,  containing  eight  per  cent  of  oxygen  by  volume,  would 
be  the  proper  amount  as  far  as  the  oxygen  is  concerned.     Sixty  per  cent 


144 


ANESTHESIA 


of  nitrous  oxid  would  be  insufficient  to  produce  tranquil  anesthesia.  By- 
using  oxygen  instead  of  air  in  the  above  equation  we  are  able  to  replace 
the  thirty-two  parts  of  useless  nitrogen  by  a  corresponding  quantity  of 
useful  nitrous  oxid,  the  percentage  of  oxygen  remaining  the  same.  The 
equation  would  now  read  like  this : 

Oxygen  =    8  per  cent  (by  volume) 

Nitrous  oxid  =  92  per  cent  (by  volume) 

This  is  about  the  average  used  with  adult  patients,  and  is  perfectly 
satisfactory. 

Administration  of  Nitrous  Oxid  with  Indefinite  Quantities  of  Oxy- 
g-en. — Willis  D.  Gatch,  formerly  of  Johns  Hopkins  Hospital,  Baltimore, 
deserves  the  credit  of  emphasizing  and  placing  upon  a  scientific  basis 
the  value  of  rebreathing.     His  apparatus  consists — besides  the  cylinders 


Fig.  28. — Diagrammatic  Sketch  Showing  Simple  Method  of  Administering  Nitrous 
Oxid  and   Oxygen  with  Indefinite   Quantities  of  the  Agents   Used. 

01  gas  and  oxygen,  and  connections — of  one  rubber  bag,  face-piece,  and  a 
two  and  a  half-inch  pipe  connecting  face-piece  and  bag.  His  mask  con- 
sists principally  of  a  rubber  cuff,  which  is  turned  down  over  the  ordinary 
mask  so  as  to  grasp  the  chin,  cheeks,  and  nose  of  the  patient.  The  patient 
may  be  made  to  breathe  air  or  gas  through  valves  or  to-and-fro  breathing 
into  the  bag.    The  main  features  of  his  apparatus  are  as  follows : 

(1)  It  is  simple,  light,  and  easily  portable. 

(2)  It  may  be  quickly  sterilized  by  boiling. 

(3)  There  is  economy  in  the  use  of  gas. 

Gatch's  Method  of  Administration.— "With  the  air-vent  open,  the  cuff 
of  the  mask  is  fitted  to  the  patient's  face,  care  being  taken  to  prevent 


NITROUS   OXID 


145 


the  admission  of  air  at  the  sides  of  the  nose.  In  some  cases  it  may  be 
necessary  to  lay  a  piece  of  gauze  across  the  bridge  of  the  nose  and  draw 
the  cuff  over  it,  or  to  hold  the  cufE  there  with  the  finger.  The  inner  tube 
of  the  valve-box  is  pushed  to  its  mid-position  and  nitrous  oxid  admitted 
to  the  bag.  The  patient  now  inhales  this  gas  and  expires  into  the  outer 
air,  thus  washing  out,  as  it  were,  all  the  air  from  his  lungs.  This  process 
is  continued  until  he  becomes  very  slightly  cyanotic.  Then  the  inner 
tube  is  pushed  to  its  final  position  and  the  patient  breathes  to-and-fro 
into  the  bag.  At  this  moment  a  small  puff  of  oxygen  is  admitted  to  the 
bag,  just  enough  to  restore  the  natural  color  of  the  face.  The  patient 
now  rebreathes  a  mixture  of  nitrous  oxid  and  oxygen  until  the  inner 
tube  of  the  valve  box  is  moved  back 
to  its  mid-position.  He  then  ex- 
hales each  breath  into  the  air  until 
the  bag  is  empty.  The  anesthetizer 
then  fills  it  with  a  fresh  mixture  of 
gases,  which  the  patient  again  re- 
breathes.  No  attempt  is  made  to 
measure  the  exact  percentage  of 
oxygen  given.  This  we  regard  as 
unnecessary.  It  is  perfectly  easy 
to  add  directly  from  the  oxygen 
cylinder  exactly  the  right  amount 
of  this  gas  to  each  bag  of  nitrous 
oxid.  The  patient's  color  is  an  ex- 
tremely delicate  indicator  of  the 
amount  of  oxygen  he  is  getting. 
Our  rule  is  to  give  just  enough 
oxygen  to  keep  the  patient's  color 
free  of  the  least  tint  of  cyanosis. 
The  most  elaborate  device  for  reg- 
ulating the  percentages  of  the  two 
gases  can  do  nothing  more  than 
this." 

All  that  is  needed  to  success- 
fully maintain  surgical  anesthesia 
with  nitrous  oxid  and  oxygen  by 
the  above  method  is  any  ordinary 
accurately  fitting  face-piece,  and  a 

mask  with  valves  that  will  also  allow  rebreathing  when  indicated,  and  a 
rubber  bag.  Any  inhaler  used  for  the  gas-ether  sequence  can  be  utilized 
to  give  gas  and  oxygen  by  the  Gatch  method.  The  stopcock  at  the  end 
of  the  bag  may  be  replaced  by  a  Y-shaped  connection  having  tubes  lead- 
ing respectively  to  the  nitrous  oxid  and  oxygen  tanks.     The  bag  is  to 


Fig. 


29. — Davis  Nitrous  Oxid-Oxygen 
Apparatus. 


' 

Fig.  30. — Davis  Apparatus  Case. — Contents:  two  100  gal.  cylinders  of  nitrous  oxid, 
one  40  gal.  cylinder  of  oxygen,  thermic  apparatus,  and  one  two-bag  gas-ether-ox\- 
gen  inhaler. 


Fig.  31.— Davis  Nitkous  Oxid-Oxygen  Apparatus  with  Vapor  Apparatus 

Disconnected. 


Fig.  32. — Davis  Nitrous  Oxid-Oxygen  Apparatus  Showing  Heater. 


Fig.   33. — Davis  Nitrous  Oxid-Oxygen  Apparatus  with  Gwathmey  Vapor  Inhalee. 


•ifar 

n 

1 

1.            -         .     -l';-:'  J 

IF     1 

j 

s 

Fig.  34. — Davis  Nitrous  Oxid-Oxygen  Apparatus  with  Gwathmey  Vapor  Inhaler. 
Same  as  Fig.  33  with  cover. 


Fig.  35. — Davis  Nitrous  Oxid-Oxygen  Apparatus  with  Gwathmey  Inhaler.    Same 

as  Fig.  31  without  cover. 


^ ^^1 

ilJIH| 

^^IRA& 

uH 

^^^^^^^^^^^M^*^  ^H^HF  i^^^lHI 

HH 

Fig.  36. — Coburn's  Apparatus  with  Anesthetic  Table  and  Cylinders  Attached. 


ReBRCATMfNG       Ba 


Fig.  37. — Coburn's  Apparatus:  Face-Piece  and  Bag. 


Fig.  38. — Coburn's  Apparatus:  Face-Piece  and  Electric  Heater. 


Fig.  39. — Gwathmey's     Nitrous  Oxid-Oxygen  Apparatus. 


NITROUS   OXID 


151 


be  kept  filled  with  nitrous  oxid,  and  a  puff  of  oxygen  is  given  whenever 
indicated  by  cyanosis  or  active  reflexes. 

While  this  apparatus  has  been  used  in  thousands  of  cases  with  satis- 
factory results,  from  the  descrij^tion  of  the  apparatus  and  the  method 
of  administration  given  above  it  can  be  readily  perceived  that,  unless  the 
strictest  attention  is  given  to  the  administration,  flaws  will  occasionally 
occur  to  mar  the  flxed  plane  of  anesthesia  that  is  to  be  aimed  for.  A 
possible  objection  outside  of  this  consideration  is  the  fact  that  the  gases 
are  not  warmed  except  by  the  rebreathing  of  the  patient,  although  they 
are  thus  properly  moistened. 

Davis'  Method.— Griffith 
Davis'  apparatus  embodies  all 
the  good  features  of  the 
Gatch  apparatus,  and,  in  ad- 
dition, all  the  nitrous  oxid  is 
passed  through  a  warming 
apparatus  before  it  enters  the 
mixing  chamber. 

Coburn  has  devised  an  ap- 
paratus for  the  administra- 
tion of  nitrous  oxid  and  oxy- 
gen, according  to  the  princi- 
ples enunciated  by  Gatch,  but 
with  the  addition  of  an  elec- 
trical heating  apparatus  for 
warming  the  gases.  Coburn's 
hospital  stand  is  very  neat 
and  compact. 

Methods  of  Administra- 
tion with  Definite  Quantities 

of  Nitrous  Oxid  and  Oxygen.— Hewitt's  Method.— Hewitt's  apparatus 
consists  of  two  bags,  one  of  which  is  used  for  nitrous  oxid  and  the  other 
for  oxygen;  and  a  mask  with  valves,  cylinders,  and  connections. 
Hewitt's  technique  consists  in  administering  the  gases  in  the  following 
manner : 

"The  bags  are  half  filled  with  their  respective  gases.  When  the 
gas  is  turned  on,  nitrous  oxid  and  a  small  percentage  of  oxygen  gain 
admission  to  the  lungs.  -  The  bags  are  kept  as  nearly  equal  as  possible 
in  size,  and  partially  distended  throughout.  The  percentage  of  oxygen 
is  gradually  increased  as  the  operation  proceeds,  but  also  occasionally 
admit  a  breath  of  fresh  air."    Hewitt  limits  the  class  of  patients  suit- 


FlG.      40. GWATHMEY      OxYGEN 

Y-PiECE  Adaptedf  or  Bennett's, 
FuRNiss',  OR  Gwathmey's  In- 
haler. 


^v 


ij 


Fig.  41. 


-Teter  Nitrous  Oxid-Oxygen  Apparatus. 


NITROUS    OXID 


153 


able  for  this  apparatus  to  weak,  anemic  men  and  middle-aged  women. 
His  experience  with  this  apparatus  has  not  been  such  as  to  recommend 
its  general  adoption. 

Gwathmey's  Method.— The  Gwathmey  apparatus  (Figs.  39  and 
40)  is  a  modification  of  Hewitt's  with  the  valve  on  the  nitrous  oxid  bag 
so  arranged  that  rebreathing  can  be  instituted  at  any  time.  Ether  can 
also  be  added  when  necessary,  and  the  nitrous 
oxid  is  heated  by  Brown's  hot-water  coil  and 
cups.  Ethyl  chlorid  can  be  given  with  the 
nitrous  oxid  and  oxygen,  if  needed.  The  ex- 
piratory valve  is  regulated  by  a  screw.  Free 
expirations  or  forced  expirations  can  thus  be 
instituted  at  will  by  the  anesthetizer.  The 
technique  is  about  the  same  as  with  the  Teter 
apparatus. 

Teter^s  Method. — One  of  the  best  ap- 
paratus yet  devised  for  the  administration  of 
nitrous  oxid  and  oxygen  for  all  purposes 
is  the  apparatus  invented  by  Charles  K. 
Teter,  of  Cleveland,  Ohio.  All  the  vapors 
inhaled  by  the  patient  are  warmed  and 
can  be  given  through  valves,  or  by  the 
method  of  rebreathing,  or  a  combination 
ot  these  two  methods,  and  at  normal  or 
positive  pressure.  The  bags  for  the  gas 
and  oxygen  are  separate,  and  a  definite  amount 
of  oxygen  is  constantly  being  mixed  with  the 
nitrous  oxid.  A  certain  amount  of  the  expired  gases  is  also  constantly 
escaping  through  the  expiratory  valve.  Warmed  ether  or  chloroform  can 
be  added  when  needed.  A  more  even  plane  of  anesthesia  is  possible  with 
this  apparatus  than  with  any  other.  A  valve  is  placed  upon  the  oxygen 
bag,  but  not  upon  the  nitrous  oxid,  which  allows  continuous  to-and- 
fro  breathing.  The  following  is  the  technique  as  given  by  Dr.  Teter 
for  the  usual  administration,  and  also  for  the  administration  through  the 
nose. 

Technique. — "Fill  the  nitrous  oxid  bag  about  two-thirds  full;  fill 
the  oxygen  bag  so  that  it  is  pretty  well  distended  and  is  under  a 
little  pressure.  Just  before  placing  inhaler  over  the  patient's  face, 
open  the  valve  from  the  nitrous  oxid  bag.  Now  place  inhaler  in  posi- 
tion, being  sure  that  you  have  perfect  coaptation  to  exclude  all  air. 
Start  the  nitrous  oxid  flowing  from  the  cylinder  into  the  bag;  this 
should  be  so  regulated  as  to  keep  this  bag  full  all  the  time.  After  the 
patient  has  been  breathing  the  pure  gas  for  about  ten  to  fifteen  sec- 
onds, the  oxygen  valve  should  be  opened  to  the  second  notch  (which 


Fig.  42.— The  Teter  Vapor 
Warmer. 


154 


ANESTHESIA 


will  be  shown  on  the  side  of  the  valve  cap  and  indicated  by  the  ratchet), 
then  keep  increasing  this  one  notch  at  a  time,  after  three  or  four  in- 


FiG.  43. — Tetbr's  Face-Mask. 


halations,  until  you  have  reached  the  fifth  or  sixth  notch;  do  not  turn 
this  any  further  unless  there   are   symptoms   of   asphyxia   manifested. 

(The  first  manifestation 
of  asphyxia  would  be  blue- 
ness  of  the  features,  which 
would  be  noticed  first  in 
the  mucous  membrane  of 
the  lips,  in  the  ears  and 
eyelids).  If  there  are 
asphyxial  symptoms  pres- 
ent, you  should  advance 
the  oxygen  valve  still  far- 
ther forward.  It  will  be 
necessary  to  start  the  oxy- 
gen flowing  from  the  oxy- 
gen cylinder  into  the  bag 
after  the  patient  has  been 
breathing  the  mixture 
about  forty  seconds,  in  or- 
der to  keep  this  bag  well 
distended  at  all  times, 
otherwise  you  would  not 
be  receiving  the  amount  of 
oxygen  indicated  or  desired.  In  order  to  keep  the  oxygen  bag  well  dis- 
tended the  oxygen  is  allowed  to  flow  very  slowly  from  the  cylinder,  so 


Fig.  44. — Teter  Ether  Attachment. 


NITROUS   OXID  155 

slowly  that  one  will  not  be  able  to  hear  it,  but  enough  to  keep  tlie  bag 
well  distended  all  the  time.  Practice  is  the  only  sure  teacher,  but  one 
is  soon  able  to  adjust  this  properly. 

"If  your  patient  is  not  going  under  the  effects  of  this  mixture  after 


Fig.  45. — Teter  Nasal  Inhaler. 

he  has  been  breathing  it  for  about  forty  seconds  or  less,  he  is  inhaling 
too  much  oxygen,  or  there  is  an  admixture  of  air.  If  the  latter  is  the 
case,  correct  it;  if  the  former,  turn  the  oxygen  valve  back  a  notch  or 
two  for  a  few  seconds,  and,  if  he  still  does  not  respond,  it  may  be  that 
the  oxygen  is  flowing  too  fast  from  the  cylinder;  if  so,  correct  this, 
and  your  patient  should  pass  into  a  sound  and  peaceful  sleep.  Of 
course,  you  will  find  some  few  patients  that  are  exceptionally  hard  to 


Fig.  46. — Teter's  Auxiliary  Tube  for  Administering  Nitrous  Oxid  and  Oxygen 
Through  the  Mouth.     Used  in  connection  with  the  nasal  inhaler. 

anesthetize,  but  by  persistence   all  patients   can   be   anesthetized  with 
nitrous  oxid  and  oxygen. 

"By  fjlose  observation  on  your  part  and  being  able  to  diagnose  symp- 
toms properly  in  order  to  know  when  to  increase  or  decrease  the  amount 
of  oxygen,  you  are  enabled  not  only  to  induce  any  desired  depth  of 
narcosis,  but  are  able  to  maintain  it  for  any  reasonable  length  of  time 


Fig.   47. — Teter  Nitrous  Oxid-Oxygen  Apparatus   with   Nasal   Inhaler   in   Use. 


Fig.     48. — Teter  Nitrous  Oxid-Oxygen  Apparatus  with   Nasal   Inhaler  in  Use, 
WITH  Surgeon  Operating. 


NITROUS    OXII) 


157 


w 


without  ever  admitting  one  breath  of  atmospheric  air.  In  fact,  you  will 
be  able  to  obtain  and  maintain  better  anesthesia  without  the  admit- 
tance of  air.     You  should  not  cause  any  jactitation  of  the  muscles,  or 

.much  if  any  cyanosis  in  producing  anesthesia.  .  .  .  Do  not  be  in  too 
much  of  a  hurry  in  bringing  your  patient  under  the  influence  of  any 
anesthetic  agent,  but  take  some  little  time  and  give  the  system  time 
to  accustom  itself  to  the  new  order  of  things.  You  will  not  only  get 
much  better  results,  but  you  will  cause  the  anesthetic  to  be  much  safer 
by  so  doing." 

Technique  to  be  Followed  in  Administering-  Nitrous  Oxid  and  Oxy- 
gen with,  the  Teter  Apparatus  and  the  Teter  Nasal  Inhaler. — "Fill  the 
respective  bags  as  stated  under  the 

heading,   'Technique  for   the   proper 

administration   of   nitrous   oxid    and 

oxygen  when  the  face  inhaler  is  to  be 

employed.'     Open  the  valve  from  the 

nitrous  oxid  bag,  then  adjust  inhaler, 

taking  the  thumbs  and  spreading  the 

lower  part  of  rubber  cap  so  that  this 

will  not  press  upon  the  alae  of  the 

nose,    tending    to    close    the    nostril. 

This  inhaler  is  so  constructed  that  by 

proper  adjustment  it  will  fit  any  nose. 

In  small  children  the  top  may  be  up 

as  high  as  the  forehead,  but  this  will 

not  matter  so  long  as  all  air  is  ex- 
cluded. 

"After  adjusting  inhaler,  instruct 

the  patient   to   breathe   through   the 

nose.     If  he  will  not  do  so,  hold  a 

piece  of  rubber  over  the  mouth.     (A 

quarter  of  a  rubber  ball  the  size  of  a 

large  orange  makes  the  best  thing  pos- 
sible for  this  purpose.)      Now  allow 

the  nitrous  oxid  to  flow  continually  so 

as  to  keep  the  nitrous  oxid  bag  full. 

After  the  first  few  inhalations  turn 

the   valve   from  the   oxygen   bag  to 

the  second  notch  and  gradually  in- 
crease this  to  the  fifth  or  sixth  notch,  as  the  symptoms  will  indicate. 

After  about  one-half  minute  you  should  start  the  oxygen  to  flowing 

from  the  cylinder  into  the   bag  very  slowly,  so   slowly  that  you  will 

not  be  able  to  hear  it,  but  enough  to  keep  this  bag  well  filled  all  the 

time. 


Fig.  49.  —  Teter's  Nasopharyn- 
geal Tubes  for  Nitrous  Oxid 
AND  Oxygen. 


158 


ANESTHESIA 


"After  inducing  the  desired  depth  of  anesthesia,  which  should  be 
accomplished  in  about  two  minutes,  remove  the  rubber  from  the  mouth. 
If  the  patient  breathes  through  the  mouth  release  the  plunger  in  the 
inhaler,  and  it  will  descend  upon  the  exhalation  disk.  This  is  done  by 
loosening  a  set  screw,  which  normally  holds  this  plunger  up  and  away 
from  the  exhalation  disk.     The  inhaler  is  to  be  held  firmly  in  position. 


Fig.  50. — The   Ohio   Monovalve.     Shown   with   warming  device,   including  ether  or 

chloroform  cup. 


Now  the  nitrous  oxid  is  turned  on  more  strongly  from  the  cylinder, 
and  the  pressure  thus  formed  in  the  bag  will  force  the  nitrous  oxid 
through  the  nose,  and,  although  the  patient  is  inhaling  and  exhaling 
through  the  mouth,  he  is  compelled  to  breathe  the  nitrous  oxid,  as 
it  is  under  pressure  greater  by  far  than  the  atmospheric  pressure. 
The  oxygen  bag  is  also  allowed  to  fill  with  oxygen,  and  this  is 
forced  along  with  the  nitrous  oxid,  according  to  symptoms  indicating 
its  need. 

"It  is  out  of  the   question  to  expect  to   maintain   as  tranquil   an 
anesthesia  by  this  method  as  is  possible  where  we  can  exclude  all  at- 


NITROUS   OXID 


159 


mospheric  air  and  are  not  hampered  in  applying  our  agent,  l)ut  we 
can  keep  our  patient  under  the  anesthetic  for  any  length  of  time  and  free 
from  all  physical  pain. 

"If  the  patient  continues  to  breathe  through  the  nose,  all  that  is 
necessary  is  to  regulate  the  oxygen  in  accordance  with  symptoms  dis- 
played and  continue  to  the  completion  of  the  operation." 

Nitrous  Oxid-Oxygen  Endopharyngeally. — Connell  has  developed  a 
very   satisfactory   method    of   administering 
nitrous  oxid  and  oxygen,  the  technique  of 
which  is  as  follows : 

After  the  patient  is  surgically  saturated 
with  the  anesthetic,  the  delivery  is  shifted  to 
the  pharyngeal  method  by  the  nasal  route. 
Each  nostril  is  plugged  by  a  collar  of  thick 
rubber  tubing  slipped  over  the  nasal  cathe- 
ters. The  pharyngeal  rebreathing  tube  is 
then  inserted,  to  which  is  attached  a  re- 
breathing  bag.  The  quantity  found  most 
useful  with  this  method  is  eight  liters  per 
minute,  beginning  with  a  five  per  cent  oxy- 
gen mixture  and  increasing  gradually  up  to 
a  nine  or  ten  per  cent  mixture  by  the  end  of 
the  first  hour.  Where  surgical  relaxation  is 
desired  and  protection  against  subconscious 
suffering  is  indicated,  this  is  to  be  obtained 
not  by  dangerously  increasing  the  oxygen 
starvation,  but  by  adding  ether  as  indicated. 
The  rebreathing  is  used  solely  for  economy. 
If  the  pharyngeal  delivery  is  22  liters,  or  five 
and  one-half  gallons,  a  minute,  rebreathing 
may  be  dispensed  with  if  the  mouth  be  kept 
closed.  (See  Connell's  Anesthetometer,  p. 
160.) 

The  Ohio  Monovalve. — The  gas  pressure 
as  it  leaves  the  cylinders  is  auiomaiically  reduced  and  controlled  here. 

In  preparing  to  give  the  anesthetic,  a  cylinder  of  nitrous  oxid  and 
oxygen  are  both  opened  as  far  as  the  valves  will  permit.  The  gas 
passes  through  regulators  which  reduce  the  pressure  to  about  two 
pounds,  then  through  automatic  valves,  where  it  is  further  reduced  to 
breathing  pressure.  The  bags  fill  automatically,  but  when  they  are 
full  the  gas  stops  flowing.  The  bags  are  refilled  as  fast  as  the  gas  is  con- 
sumed. 

There  is  only  one  valve  to  handle.  With  it,  pure  nitrous  oxid  is 
given,  and  when  it  is  turned  beyond  a  certain  point  oxygen  is  mixed 


1^ 

mW^Fr^ 

T  iT^ 

.-%:' 

h^ 

i5^^=U*              1 

1 

I    bB 

1 

B   l^B 

wk   ^B^^ 

J 

1^ 

1 

B 

I 

9^W 

Fig.  51. — Ohio  Small  Ni- 
trous Oxid  Inhaler.  May 
be  easily  carried  to  bedside 
or  hospital  ward;  very 
satisfactory  for  short  an- 
esthesia. 


160 


ANESTHESIA 


in  fixed  percentage.     If  turned  still  farther,  the  nitrons  oxid  is  closed 
off  and  pure  oxygen  is  administered. 

If  the  patient  is  a  deep  breather,  the  gas  can  be  given  with  in- 
creased force  by  simply  turning  a  regulating  device  on  top  of  the 
nitrous'  oxid  and  oxygen  automatic  valves.     These  are  close  to  the  one 


Fig.  52. —  Connell,'s  Anesthbtometer. 

valve  referred  to,  and  are  so  easy  to  operate  that  there  is  no  danger  of 
confusion. 

The  monovalve  is  made  in  two  designs,  one  especially  for  offices 
and  hospitals,  where  it  is  easily  moved  about  on  castors,  and  another 
design,  which  can  be  packed  up  and  carried  around  from  place  to  place. 

Boothby  and  Cotton  Apparatus. — The  apparatus  of  Boothby  and 
Cotton  seems  to  mark  a  distinct  step  in  advance.  The  apparatus 
is  not  portable,  but  is  especially  applicable  for  hospital  use. 


NITROUS    OXID  161 

a  perfected  apparatus'  with  notes  on  administration  => 

"Desirability  of  Constant  Mixture  and  Necessity  of  Ether 
Addition. — All  experimental  and  clinical  worlv  lias  emphasized  the 
fact  that  a  constant  mixture  (rightly  proportioned  for  the  particular 
case  in  hand)  produces  a  smoother  anesthesia  than  a  mixture  of  vary- 
ing composition;  in  other  words,  it  has  been  shown  that  an  intermit- 
tent and  irregular  supply  of  either  gas 
does  not  conduce  to  a  smooth  surgical  an- 
esthesia. 

"Hewitt  was  the  first  to  develop  an  ap- 
paratus at  all  applicable  for  general  surgi- 
cal use.  His  methods  of  overcoming  the 
pressures  of  the  nitrous  oxid  and  oxygen 
in  the  tanks  is  to  use  semi-elastic  bags 
which  are  kept  more  or  less  full  from  the 
tanks  by  means  of  an  intermittent  flow  of 
the  gases  controlled  directly  by  hand 
valves.  From  these  bags  the  flow  of  gas 
to  the  patient  is  regulated  by  a  specially 
constructed  and  graduated  valve  that  al- 
lows definite  proportions  of  gas  to  pass 
from  each  bag,  providing  the  pressures 
within  the  same  are  equal. 

"In  practice  it  has  been  found  very 
difficult  to  keep  the  two  bags  evenly  and 
equally  distended,  even  if  great  pains  and 
constant  attention  are  being  given  by  the 
operator  to  the  manipulation  of  the  hand 
valves;  therefore,  the  pressure  in  the  two 
bags  varies  and,  consequently,  the  mix- 
ture actually  received  by  the  patient  must 
of  necessity  be  very  varied. 

"Fundamental       Principles.     In- 
volved   IN    Securing    Constant    Mix- 
tures.— As  a  result  of  the  inadequacy  of  any  apparatus  built  on  the 
principle  of  the  Hewitt,  we  took  up,  now  over  a  year  ago,  the  study 
of  the  problem.      We   laid    down   four   fundamental   principles   which 
were  to  be  met,  namely: 

^See  Figs.   54-55. 

*  Written  by  Frederic  J.  Cotton,  First  Assistant  Surgeon,  Boston  City  Hos- 
pital, and  Walter  M.  Boothby,  Assistant  in  Anatomy,  Har^-ard  Medical  School, 
Assistant  Surgeon,  Mount  Sinai  Hospital  (Boston,  Mass.),  Anesthetist  to  the 
Boston  City  Hospital, 


Fig.  53. — Pressure  Gauges  for 
Large  Tanks  of  Nitrous 
Oxid  and  Oxygen. 


162 


ANESTHESIA 


"(1)  There  must  be  an  absolutely  regular  flow  of  each  gas  at  any 
rate  desired,  without  the  necessity  of  frequent  valve  manipulation. 

"(2)  The  flow  of  the  gases  must  be  rendered  visible  so  that  their 
proportions  can  be  approximately  estimated  at  a  glance. 

"(3)   Kn  efficient  method  of  adding  ether  vapor  gradually  yet  rap- 


1C 

ife-. 

<<wW^ftNi  MfJ'!-' 

Fig.  54. — Boothby  and  Cotton  Apparatus  Set  Up.  (See  page  169.) 


idly  up  to  any  amount  that  even  an  extreme  case  may  require  must  be 
available. 

"(4)  The  face-piece  must  be  so  modified  as  to  be  absolutely  air- 
tight and  also  practically  self-retaining. 

"Maintaining  Eegular  Flow  of  Gases. — The  first  point,  the 
crucial  one,  is  to  obtain  an  even  fiow  of  nitrous  oxid  gas  from  its 
liquefied  form.  This  necessitates  the  use  of  an  automatic  reducing 
valve.  The  same  is  true  of  oxygen,  although  not  in  liquid  form,  in  simi- 
lar tanks  under  a  pressure  of  1,500  to  1,800  pounds  to  the  square  inch. 
The  province  of  such  a  valve  is  to  reduce  these  pressures  to  a  working 
basis  of  20  pounds  to  the  square  inch;  a  good  valve  should  act  auto- 


NITROUS   OXID  163 

matically,  and   require   no   attention   on   the   part   of   the   anesthetist; 
furthermore,  it  does  not  freeze  or  become  otherwise  obstructed. 

"This  principle  of  the  automatic  reduction  of  high  tank  pressures 
is  so  fundamental  that  we  consider  it  essential  that  this  feature  be 
actually  an  integral  part  of  the  apparatus  and  not  secondarily  attached 


Fig.  55. — Boothby  and  Cotton  Apparatus  Folded.  (See  page  170.) 

to  tanks  which  are  then  connected  to  an  apparatus  designed  on  the 
Hewitt  type.  For  general  use  a  tank  of  moderate  size  (containing  75 
gallons  of  oxygen  and  250  gallons  of  nitrous  oxid)  is  the  most  prac- 
tical and  convenient;  accordingly  we  have  designed  our  apparatus  for 
that  size  of  tank  (the  smaller  sizes  can  of  course  be  used  and  are  pref- 
erable for  transportation  in  house  operating) . 

"Visible  Control  of  Flow  of  Gases. — The  second  desideratum, 
namely,  rendering  tlie  rate  of  flow  of  gases  visible,  so  that  the  relative 
proportion  of  each  gas  may  be  estimated  at  a  glance  (also  assuring  the 
administrator  of  the  fact  that  the  desired  flow  is  actually  taking  place) 
has  been  solved  by  having  each  gas  huthle  separately  through  water 
into  a  glass  mixing  chamber. 

"The  volume  of  gas  delivered  to  the  patient  is  controlled  by  means 


164  ANESTHESIA 

of  a  hand  valve  of  fine  adjustment  acting  against  the  loio  pressure  de- 
livered by  the  reducing  valve.  This  is  entirely  independent  of  the 
automatic  reducing  valve.  The  hand-valves  can  be  set  to  give  any 
desired  volume,  which  will  continue  unaltered  for  hours;  a  change  in 
the  rate  of  flow  is  obtained  by  simply  turning  the  valve-handle  a  trifle 
till  such  volume  per  minute  as  is  desired  is  seen  to  bubble  through  the 
water  of  the  mixing  chamber. 

"The  aim  of  the  anesthetist  is  to  determine,  as  early  in  the  anes- 
thesia as  possible,  the  proportion  of  nitrous  oxid  and  oxygen  suited  to 
the  patient  under  his  care.  The  greater  his  experience  the  earlier  will 
he  be  able  to  do  this  with  certainty.  After  this  proportion  is  once 
ascertained  the  apparatus  will  deliver  the  same  mixture  as  long  as  de- 
sired. After  a  brief  experience  one  is  enabled  to  approximate  the  de- 
sired proportion  solely  by  the  eye,  thus  rendering  it  easier  to  quickly 
obtain  the  constant  mixture  needed  for  the  particular  patient  in  hand. 
In  difficult  cases  it  greatly  helps  the  anesthetist  to  determine  whether 
the  patient  becomes  rapidly  cyanotic  (and  this  is  not  a  rare  occurrence 
with  beginners)  ;  the  anesthetist  can  see  at  a  glance  that  the  cause  of 
the  difficulty  is  obstruction  of  the  respiratory  passages  and  not  due  to 
an  insufficient  proportion  of  oxygen  in  the  mixture  being  administered 
to  the  patient. 

"Addition  of  Ether  Vapor. — The  third  essential  point,  which 
consists  of  being  able,  gradually  yet  rapidly,  to  add  to  the  respired 
mixture  ether  vapor  (as  much  as  an  extreme  case  may  need),  has 
been  met  by  providing  a  second  chamber,  containing  ether.  The  gases, 
after  leaving  the  mixing  chamber,  pass  to  a  three-way  valve  by  which 
they  are  allowed  to  pass  by  the  ether  chamber  entirely,  or  are  made  to 
pass  either  partly  or  wholly  over  the  surface  of  the  ether,  or  they  may 
be  forced  (if  desired)   to  bubble  through  the  ether. 

"Thus  any  amount  of  ether  vapor  required,  from  the  minutest  trace 
to  a  relatively  high  percentage,  can  he  almost  instantly  obtained. 

"The  possibility  of  gradually  and  yet  rapidly  increasing  the  strength 
of  the  ether  vapor  is  a  material  advantage,  for  it  allows  the  anesthetist 
to  just  'catch'  the  patient  within  a  few  seconds  after  he  gives  a  sudden 
warning  of  being  'light'  by  moving  the  legs,  contracting  the  abdominal 
wall,  or  showing  symptoms  of  impending  vomiting.  At  such  moments 
one  may  gradually  but  rapidly  increase  the  ether  percentage  to  that 
obtained  by  bubbling  through  the  ether;  after  a  few  respirations  the 
patient  is  seen  to  relax  or  the  symptoms  of  impending  vomiting  dis- 
appear, at  which  time  the  ether  should  be  entirely  shut  off.  It  is  best, 
as  a  rule,  at  the  beginning  of  trouble  indicating  a  'light'  condition,  to 
make  no  change  in  the  rate  of  flow  of  the  gas  or  oxygen,  for  when  ether 
is  administered  a  slight  excess  of  oxygen  is  desirable;  but,  as  soon  as 
the  impending  trouble  is  overcome,  the  rate  of  oxygen  may  be  slightly 


NITROUS   OXID  165 

decreased,  or  that  of  nitrous  oxid  increased,  depending  on  the  amount 
of  rebreathing  desired.  In  all  probability  the  new  mixture  will  main- 
tain a  perfect  condition  of  anesthesia  for  the  rest  of  the  operation, 
possibly  without  the  necessity  of  again  touching  tlie  valves. 

"Because  we  have  emphasized  the  necessity  of  having  available  an 
appliance  by  which  strong  ether  vapor  can  be  administered  we  must 
not  be  misunderstood ;  in  at  least  one  quarter  of  the  cases  no  ether  at 
all  will  be  required;  in  perhaps  another  quarter  about  two  minutes' 
inhalation  of  ether  will  be  needed  during  the  last  stages  of  the  prepa- 
ration of  the  patient;  in  another  small  proportion  an  occasional  addi- 
tion of  ether  vapor  for  one  or  two  minutes  through  the  course  of  the 
administration  will  be  found  advisable;  only  very  rarely  and  in  re- 
bellious alcoholic  cases  will  more  than  a  total  of  ten  minutes'  respira- 
tion of  ether  in  addition  to  the  gas  mixture  be  needed  for  an  hour's 
operation;  and,  even  in  these  difficult  cases,  practically  no  more  ether 
is  needed  after  the  first  hour,  no  matter  how  long  the  operation  is  pro- 
longed. Accordingly  little  or  no  nausea  and  vomiting  follows  a  prop- 
erly conducted  nitrous  oxid-oxygen-ether  anesthesia  in  a  great  ma- 
jority of  cases. 

"Pre-medication". — The  cases  run  somewhat  more  smoothly,  and 
perhaps  with  an  average  decrease  in  the  amount  of  ether  vapor  needed, 
resulting  in  a  more  nearly  ideal  recovery,  if  moderate  doses  of  mor- 
phin  (gr.  %  to  14)  and  of  atropin  (gr.  1-120  to  1-100)  are  given 
hypodermically  one-half  hour  before  the  beginning  of  the  anesthesia.^ 
At  the  Boston  City  Hospital  this  is  a  standing  order,  but  if  it  is  omitted 
for  any  reason  we  are  not  concerned  except  in  the  case  of  bad  alcoholics. 
In  other  words,  the  preliminary  injection  of  morphin  is  by  no  means 
essential,  though  it  is  desirable  unless  contradicted  by  some  known 
peculiarity  of  the  patient. 

"jSTon-leaking  Face-piece. — The  fourth  point  necessary  for  a 
nitrous  oxid-oxygen  ^  anesthesia  is  to  exclude  even  traces  of  air  from 
leaking  in  between  the  mask  and  the  face.  This  necessity  holds  true 
for  every  case  and  must  be  accomplished  in  spite  of  peculiarities  of  th^ 
facial  contour  or  the  presence  of  beard  and  whiskers.  Boothby  ^  recently 
described  a  collar  that  is  not  only  air-tight  but  practically  self-retain- 
ing. To  those  using  this  collar  we  call  attention,  elsewhere  more  fully 
dealt  with,  of  the  dangers  of  positive  pressure;  the  expiratory  valve 
must  be  so  set  that  an  outflow  of  the  gases  may  occur  whenever  the 
pressure  inside  the  masks  exceeds  2  mm.  of  mercury,  which  is  a  pres- 

'  In  the  beginning,  following  the  lead  of  Crile,  we  used  seopolamin  with  the 
morphin.  Often  an  efficient  hypnotic,  seopolamin  has  seemed  to  us  too  uncer- 
tain in  its  action  to  be  worthy  of  routine  use,  and  we  have  come  to  use  atropin, 
which  does  at  least  reliably  insure  us  against  trouble  from  excess  of  mucus. 

'Boston  Med.  and  Surg.  J.,  1912,  166,  9,  328, 


166 


ANESTHESIA 


sure  that  is  just  sufficient  to  maintain  the  rebreathing  bag  full  but 
not  distended. 

"Rebreathing  Eegulated. — For  an  even  anesthesia,  and  as  an  aid 

to  the  avoidance  of  surgical 
sliock,  a  certain  constant 
amount  of  rebreathing  is  of 
benefit ;  approximately  the 
rate  of  flow  of  the  gases 
should  be  such  that  from  a 
quarter  to  a  half  of  the  vol- 
ume of  each  respiration  is 
of  freshly  added  gas  mix- 
ture. Such  a  proportion  re- 
duces to  within  reasonable 
limits  the  expense  of  gas- 
oxygen  anesthesia ;  too 
much  rebreathing  is  apt  to 
be  followed  by  post-opera- 
tive discomfort,  usually  in 
the  form  of  headache,  and 
it  may  cause  an  increase  of 
post-operative  nausea  and 
vomiting.  Vomiting  dur- 
ing the  progress  of  the  an- 
esthesia is  often  an  indica- 
tion of  excessive  rebreathing 
for  that  particiilar  patient, 
although  in  comparison 
with  other  patients  it  may 
not  appear  excessive;  at  all 
events,  increasing  the  vol- 
ume per  minute  of  the  gas 
mixture  frequently  clears 
up  the  symptoms.  Our  ob- 
servations on  the  effect  of 
rebreathing,  so  far  as  they 
go,  agree  clinically  with  the 
laboratory  findings  of  Hen- 
derson. Our  observation  of 
the  blood  pressure  under  nitrous  oxid-oxygen  (ether)  anesthesia  is  that 
there  is  a  distinct  rise  not  only  at  the  commencement  but  also  through- 
out the  operation.  After  the  removal  of  the  mask  with  its  accompany- 
ing necessity  for  rebreathing,  there  is  a  distinct  and  rapid  fall  in  the 
blood  pressure.     In  two  instances,  both  on  very  sick  and  debilitated 


Fig.  56. — Boothby  and  Cotton  Face  Mask. 


NITROUS   OXID  167 

patients,  this  fall  was  sufficient  to  abolish  the  radial  pulse ;  the  appear- 
ance of  the  patients  and  their  mental  attitude  remained  good;  recovery- 
was  prompt  and  within  one-half  hour  they  were  in  fine  condition  and 
remained  so. 

"Avoidance  of  Cyanosis. — Surgical  anesthesia  is  never  obtained 
when  the  patient  appears  in  the  least  degree  cyanotic  on  account  of 
asphyxial  spasm  and  rigidity.  On  the  contrary  the  patient  must  al- 
ways he  pink.  Any  anesthesia  accompanied  by  cyanosis  is  dangerous. 
Deaths  under  nitrous  oxid-oxygen  are  doubtless  due  to  conducting 
the  anesthesia  according  to  the  erroneous  idea  of  the  necessity  and 
safety  of  cyanosis;  no  deaths  have  been  reported  in  which  the  patient's 
color  was  maintained  pink. 

"We  have  suggested  that,  in  some  cases,  even  when  respiring  a  mix- 
ture of  gas  and  oxygen  in  which  the  proportion  of  the  latter  is  sufficient 
to  maintain  a  pink  color,  the  patient  might  be  brought  under  too  pro- 
found an  influence  of  nitrous  oxid,  and  the  anesthesia  be  made  danger- 
ously deep.  Our  use  of  an  absolutely  air-tight  face-piece  has  enabled  us 
to  demonstrate  that  such  a  condition  occurs  not  infrequently.  In  fact, 
toward  the  end  of  a  long  operation  it  is  often  necessary  to  use  equal  parts 
of  oxygen  and  nitrous  oxid. 

"The  symptoms  of  an  overdose  of  nitrous  oxid  in  the  presence  of 
sufficient  oxygen  to  keep  the  patient  pink  is,  first,  stertorous  respiration, 
and  second,  the  onset  of  an  excessive  secretion  of  mucus;  unless  the 
percentage  of  nitrous  oxid  is  then  decreased,  the  patient's  face  and  hands 
take  on  a  death-like  pallor  (not  cyanotic)  ;  there  is  an  absolute  loss  of  all 
the  facial  reflexes;  the  respirations  become  shallow;  and  probably  the 
blood  pressure  falls  (that  is,  the  temporal  cannot  be  found  so  readily 
although  the  rate  is  not  excessive).  This  condition,  if  pushed,  would 
probably  lead  to  death  from  paralysis  of  the  respiratory  center,  though 
we  know  of  no  experimental  evidence  to  support  the  hypothesis. 

"The  point  we  wish  to  make  is  that  an  excess  of  nitrous  oxid  may 
be  given  even  with  a  proportion  of  oxygen  sufficient  to  maintain  the 
patient  pink  and  the  respirations  normal;  if  a  death-like  pallor  with 
the  other  symptoms  noted  should  now  supervene  while  respiring  such 
a  mixture,  the  patient  is  rapidly  approaching  the  danger  point  of  ex- 
cessive anesthetization.  In  such  a  condition  no  time  should  be  lost, 
for  as  yet  we  do  not  know  how  soon  actual  respiratory  failure  and  death 
may  occur.  In  brief,  the  mask  should  be  removed,  and,  if  necessary, 
artificial  respiration  instituted  together  with  the  administration  of  oxy- 
gen. 

"The  use  of  nitrous  oxid  for  prolonged  anesthesia  is  still  in  its  in- 
fancy and  its  danger  limits  are  not  well  understood;  in  consequence, 
for  several  years  yet  its  effects  must  be  carefully  watched. 

"When  Ether  Should  Be  Added  to  the  Mixture. — Although  the 


168  ANESTHESIA 

patient  is  rapidly  rendered  unconscious  (two  minutes)  by  nitrous  oxid- 
oxygen,  yet  it  is  nearly  ten  minutes  before  the  body  is  sufficiently  satu- 
rated with  the  nitrous  oxid  to  permit  the  beginning  of  an  abdominal 
operation.  During  this  period,  which  may  be  occupied  by  the  prepa- 
ration and  draping  of  the  patient,  we  allow  the  anesthetist  to  depart 
somewhat  from  our  rule  in  regard  to  avoidance  of  cyanosis;  but  even 
here  we  permit  only  the  slightest  degree  of  duskiness  and  never  enter- 
tain the  possibility  of  deep  cyanosis.  By  the  time  the  incision  is  made 
the  patient  must  be  actually  pink  and  remain  so  throughout  the  oper- 
ation. If  then  a  mixture  of  nitrous  oxid  and  oxygen  with  a  propor- 
tion of  the  latter  sufficient  to  keep  the  patient  pink  will  not  produce 
sufficient  relaxation  to  meet  the  demands  of  the  surgeon,  the  anesthetist 
must  add  ether  vapor  till  relaxation  is  complete. 

"For  the  best  results  close  cooperation  on  the  part  of  the  surgeon 
and  the  anesthetist  is  essential.  During  the  greater  part  of  the  ma- 
jority of  operations  complete  relaxation  is  not  needed;  when  such  re- 
laxation is  required  by  the  surgeon  he  should  so  inform  his  anesthetist, 
who  will  be  able  within  two  minutes,  by  the  proper  administration  of 
ether,  to  provide  the  same ;  as  soon  as  such  need  is  over  the  ether  may 
be  discontinued. 

"Obstruction  of  the  Air  Passages. — ^A  cyanotic  condition  of  the 
patient,  however,  sometimes  quickly  develops  even  with  an  evidently 
liberal  supply  of  oxygen  as  shown  by  the  flow  through  the  mixing 
chamber.  In  such  cases  the  trouble  is  without  question  an  obstruction 
of  the  air  passages  and  must  be  quickly  remedied.  Contrary  to  the 
generally  accepted  opinion,  cheek  and  tongue  obstruction  of  the  air  pas- 
sages is  extremely  common  under  nitrous  oxid-oxygen  anesthesia,  and 
its  prevention  is  absolutely  essential.  The  most  frequent  cause  is  an. 
obstruction  of  the  nares  together  with  a  valve-like  action  of  the  lips 
or  cheeks  against  the  teeth  that  occurs  in  mouth  breathing  when  there 
is  muscular  relaxation.  A  ready  means  of  overcoming  such  a  condi- 
tion is  to  slip  up  under  the  face-piece  or  collar  a  piece  of  gauze  or  a  thin 
ribbon  retractor  into  the  angle  of  the  mouth  to  keep  the  lips  apart  and 
the  cheek  away  from  the  teeth;  or  pieces  of  rubber  tubing  about  six 
inches  long,  guarded  by  safety  pins,  may  be  introduced  into  the  nares 
through  the  oro-pharynx.  In  rare  cases  the  tongue  may  drop  back  and 
cause  obstruction  in  spite  of  every  effort  to  prevent  the  same  by  hold- 
ing the  jaw  forward;  in  such  cases  a  silkworm-gut  stitch  should  be 
passed  through  the  tongue  and  brought  out  under  the  collar,  with  a 
dental  mouth  prop  placed  between  the  teeth  to  prevent  biting  of  the 
tongue.  An  absolutely  free  air  passage  for  the  gases  must  always  be 
maintained;  any  slight  obstruction,  most  commonly  on  inspiration, 
causes  a  labored  respiration  under  which  conditions  a  smooth  anes- 
thesia is  impossible ;  besides  it  throws  an  extra  exertion  onto  the  patient. 


NITROUS   OXID  169 

"The  theoretical  benefit  to  be  obtained  from  an  increase  of  pressure 
is  less  than  one  per  cent  in  efficiency ;  accordingly,  a  procedure  embody- 
ing the  dangers  of  collapse  and  of  sudden  death,  with  such  a  meager 
beneficent  return,  should  not  be  used. 

"In  practice,  therefore,  the  rebreathing  bag  should  just  become 
taut  at  the  end  of  an  expiration ;  this  corresponds  to  a  pressure  of  one 
or  two  mm.  of  mercury,  which  is  sufficient  to  open  the  respiratory 
valve  at  the  end  of  the  expiration,  and  thus  to  allow  the  last  part  of 
the  expired  gases,  that  part  which  (as  McKessen  points  out)  contains 
the  largest  percentage  of  COo  to  escape  into  the  air. 

"The  experimental  apparatus  recently  described  by  us,  built  on  the 
principles  enunciated  above  without  regard  to  lightness  and  portability, 
has  been  most  satisfactory  and  has  met  all  expectations.  We  have  re- 
versed our  former  opinion  as  to  the  desirability  of  having  an  attach- 
ment for  warming  the  gases  and  this  attachment  has  been  discarded. 

"An  apparatus  to  meet  all  requirements  described  above  must  have 
some  size  and  weight.  These  items,  however,  have  been  reduced  to 
their  lowest  terms  by  great  care  in  the  design  and  arrangement  of  the 
various  parts.  For  the  purpose  of  transportation  the  apparatus  can  be 
collapsed  to  a  reasonable  carrying  size  (height,  17  inches;  length,  22 
inches;  width,  I714  inches)  by  the  simple  removal  of  four  lag  bolts, 
set  up  with  thumb  screws,  which  allows  the  top  half  of  the  machine  to 
swing  down  into  the  lower  half;  tii,  center  bar  or  axis  acts  then  as  a 
convenient  handle  and  the  framework  forms  a  protecting  cage  for  the 
valves  and  the  glass  chambers.  To  reduce  the  weight,  the  patterns  have 
been  made  as  small  as  is  consistent  with  the  strength  requisite  for  hard 
hospital  use  and  transportation  for  house  operating,  and  the  castings 
(except  the  valves)  are  made  of  aluminum  alloy.  The  carrying  weight 
is  just  under  fifty  pounds. 

"Fig.  I.^  (1)  Hand  valve  to  regulate  the  volume  supply  of  oxy- 
gen; it  works  against  a  low  pressure  of  about  25  pounds  to  the  square 
inch,  therefore  it  can  be  set  for,  and  will  continue  to  deliver,  any  con- 
stant amount,  and  this  can  be  estimated  by  seeing  the  rate  of  flow  as 
the  gas  bubbles  through  the  water  in  the  glass  mixing  chamber    (7). 

"(2)  Ether  valve;  when  pushed  over  to  the  left  the  mixed  gases 
from  7  go  directly  to  the  patient;  when  in  the  center  (as  illustrated) 
the  mixed  gases  pass  over  the  surface  of  the  ether  in  chamber  8 ;  when 
pushed  over  to  the  right  the  gases  must  bubble  through  the  ether. 

"(3)  Hand  valve;  to  control  the  volume  of  nitrous  oxid  in  same 
manner  as  (1)   regulates  oxygen. 

"(4)  Low  pressure  gauge;  the  one  on  the  left  indicates  the  pressure 
of  oxygen,  and  that  on  the  right  nitrous  oxid,  after  being  automatically 
reduced  by  the  reducing  valve. 

*See  Fig.  54,  page  162, 


170  ANESTHESIA 

"(5)   Eegulating  handle  on  the  reducing  valve;  this,  after  being  set 

for  the  desired  low  pressure  (30  lb.),  does  not  need  to  be  again  touched. 

"(6)   High  pressure  gauge;  to  show  the  pressure  in  the  supply  tank. 

"(7)  Glass  mixing  chamber;   contains  water  through  which   each 

gas  bubbles  separately,  thus  giving  a  ready  means  of  estimating  at  a 

glance  the  rate  of  flow  of  both  the  oxygen  and  the  nitrous  oxid. 

"(8)  The  ether  chamber;  by  valve  2  the  gases,  after  being  mixed 
in  7,  are  allowed  to  pass  around  the  ether  chamber  or  made  to  pass 
partly  or  wholly  over  the  surface  of  the  ether,  or  forced  to  bubble 
through  the  ether,  thus  adding  any  desired  amount  of  ether  vapor  toi 
the  respired  mixture. 

"(9)  One  of  four  valves;  introduced  so  that  any  one  of  the  tanks 
may  be  removed  and  replaced  by  a  full  one  without  interrupting  the 
use  of  the  apparatus. 

"(10)    Cups  to  fill  the  chambers  with  water  and  ether, 
"(a)  Valve  on  tank. 

"(b)    Screw  by  which  each  tank  is  clamped  into  its  yoke. 
"(c)    One  of  the  two  nitrous  oxid  tanks  on  right  side. 
"(d)    One  of  the  two  oxygen  tanks  on  left  side. 
"(e)   Eebreathing  bag. 
"(f)   Mask  with  celluloid  face-piece  and  the  Boothby  air-tight 

self-retaining  collar. 
"(h)   Two  of  the  four  lag  bolts  which  may  be  removed  by  un- 
screwing the  thumb  nuts  on  the  inside  to   allow  the 
top  of  the  table  to  invert  into  the  lower  half, 
"(i)    Center  axis  on  which  the  top  half  swings. 
"Fig.  11.^  (1)  Center  axis  on  which  the  top  half  swings;  the  middle 
portion  serves  as  a  handle. 

"(2)  One  of  the  four  thumb  nuts  which  are  removed  to  invert  the 
table. 

"(3)  Mixing  and  ether  chamber  protected  by  the  frame  when  top 
is  inverted  for  transporting. 

"(4)  Pet  cocks  for  drawing  off  the  water  and  ether  from  the  cham- 
ber before  inverting. 

"(5)   The  under  side  of  one  of  the  automatic  reducing  valves. 
"(6)   The  metal  nipple  to  which  the  rubber  tube  is  attached  that 
leads  to  the  rebreathing  bag. 

"Size:  Height,  17  inches;  length,  22  inches;  width,  I714  inches; 
weight,  50  pounds    (aluminum  castings)." 

The    Gwathmey-Woolsey    Nitrous    Oxid-Oxygen    Apparatus. — The 

Gwathmey-Woolsey  apparatus  has  been  developed  in  accordance  with 

the  principles  recognized  as  essential  in  the  evolution  of  nitrous  oxid  and 

oxygen  anesthesia,  especially  those  utilized  by  Gatch  and  by  Boothby 

^  See  Fig.  55,  page  163. 


NITROUS   OXID 


171 


and  Cotton.  The  gas  supply  is  conveniently  and  efficiently  furnished 
when  equipped  for  portable  use,  first,  by  two  one  hundred  gallon  tanks 
of  nitrous  oxid  which  are  in  direct  connection  with  the  reducer  at  all 
times;  second,  by  one  forty  gallon  tank  of  oxygen,  easily  and  quickly 
replaced  when  necessary. 

The  pressure  of  the  nitrous  oxid  is  reduced  by  an  efficient  reducer 
of  small  dimensions  and 
light  weight;  that  of  the 
oxygen,  by  a  very  small 
valve.  The  gases  are  deliv- 
ered under  low  pressure 
into  a  combination  sight 
feed  and  warm  water  bath, 
where  the  administrator 
can  see,  on  one  side  of  a 
nickel  partition,  the  nitrous 
oxid  flowing,  and  on  the 
other  the  oxygen.  This 
sight  feed  enables  the  anes- 
thetist to  regulate  the  pro- 
portions of  the  gases  very 
carefully. 

This  water  sight  feed  is 
warmed  by  an  alcohol  lamp 
adjustable  to  its  under  sur- 
face, thus  supplying  heat 
and  moisture,  which  are 
valuable  assets  in  the  ad- 
ministration of  any  anes- 
thetic. From  the  sight 
feed,  the  mixed  gases  pass 
at  the  top  through  an  exit 
tube  to  which  is  attached 
the  rubber  tube  running  to 
the  rubber  bag  and  mask. 
The  gas  cylinders  are 
opened  wide  into  the  re- 
ducing valves,  the  flow 
from  these  valves  being  controlled  by  very  sensitive  wheels. 

When  the  two  nitrous  oxid  tanks  and  one  oxygen  tank  are  in 
place  (enough  for  a  two-hour  administration),  the  total  weight  is  under 
forty  pounds.  In  hospitals  where  the  supply  is  obtained  from  large 
tanks  or  from  a  generator  in  the  cellar,  the  delivery  hose  from  these 
sources  may  be  attached  to  the  apparatus. 


Fig.  57. — Gwathmet-Woolset  Nitrous  Oxid- 
OxYGEN  Apparatus.  R,  reducing  valve  of  ni- 
trous oxid;  B},  regulating  valve  of  nitrous  oxid; 
O,  regulating  valve  for  oxygen;  F,  sight  feed; 
S,  supports. 


172 


ANESTHESIA 


The  Gwathmey-Woolsey  Mask. — The  Gwathmey-Woolsey  mask 
is  an  anatomical  one  made  to  fit  the  bones  of  the  face.  A  rubber  collar, 
devised  first  by  Gatch  and  later  nsed  by  Boothby  and  Cotton,  is  retained 
as  an  essential  feature  of  the  mask.  The  adjustment  of  this  collar,  to  the 
absolute  exclusion  of  all  air,  is  considered  one  of  the  important  features 
of  the  technique. 

Ether. — In  the  small  number  of  cases  in  which  it  is  necessary  to 


Fig.   58. — Gwathmey-Woolsey   Nitrous  Oxid-Oxygen  Apparatus  with   Cylinders 
Attached.    O,  regulating  valve  for  oxygen;  O2,  oxygen  tank;  N2O,  nitrous-oxid  tank. 


give  ether  in  combination  with  gas  and  oxygen  it  may  be  introduced 
by  placing  an  ether  chamber  directly  on  the  mask  and  between  the 
mask  and  bag,  as  is  usual  with  all  gas-ether  apparatus.  The  chimney 
piece  of  the  Gwathmey  gas-ether  apparatus,  to  which  the  gas  bag  is 
attached,  has  been  retained.  This  contains  the  inspiratory  and  ex- 
piratory valves  upon  a  sliding  cuff.  With  this  cuff,  the  anesthetist  can 
regulate  the  patient's  breathing,  through  valves,  partly  through  valves, 
rebreathing  entirely,  or,  as  is  generally  the  case,  rebreathing  with  the 
expiratory  valve  slightly  open. 

Positive  Pressure. — Five  mm.  of  mercury  pressure  in  the  re- 
breathing bag  have  been  found  a  very  great  help  in  those  subjects 
usually  considered  unsuitable  for  nitrous  oxid  and  oxygen. 


NITROUS   OXID  17b 

Endotracheal  Insufflation. — The  apparatus  was  especially  de- 
vised for  endotracheal  work.  If  has  heen  found  most  acceptable  wher- 
ever endotracheal  work  is  needed,  the  constant  flow  of  the  gases  insur- 
ing an  even  anesthesia  without  danger.  When  used  in  this  way,  no  bag 
is  necessary,  the  connection  being  made  directly  with  the  tube  in  the 
trachea.  The  cases  in  which  it  has  been  used  have  been  entirely  satis- 
factory. The  patient  is  anesthetized  in  the  usual  way,  the  catheter  is 
inserted  in  the  trachea,  and  a  glass  connecting  tube  is  placed  in  the 
catheter,  joining  it  with  the  rubber  tube  from  the  apparatus. 

A  mercurial  manometer  which  automatically  "blows  off"  at  twenty- 
five  mm.  of  mercury  pressure  is  attached  for  endotracheal  work.  For 
the  usual  anesthesia,  a  safety  valve  set  for  a  pressure  of  ten  pounds 
protects  the  glass  "sight  feed." 

Nasal  Anesthesia  for  Oral  Surgery. — For  such  operative  pro- 
cedure the  bag  can  be  dispensed  with  and  the  general  principles  outlined 
by  Teter  allowed  to  govern  the  technique.  The  Teter  auxiliary  tube 
for  the  mouth,  to  prevent  spattering  when  the  volume  of  gas  is  too 
great  through  the  nasal  passages,  is  also  used.  This  method  is  entirely 
satisfactory  in  cases  of  adenoids  and  tonsils. 

Analgetic  Work. — With  the  nose-piece  in  position,  a  great  many 
surgical  operations,  especially  dental  work,  may  be  done  with  ease  dur- 
ing the  analgetic  stage  of  nitrous  oxid-oxygen  anesthesia.  The  ab- 
sence of  the  bag,  or  any  impediment  around  the  patient's  head,  is  a 
very  great  advantage.  The  automatic  action  of  the  apparatus  after 
once  the  flow  of  gases  is  started  is  a  great  help.  It  is  now  an  acknowl- 
edged fact  that  dentists  can  do  their  work  more  acceptably  to  the  pa- 
tient and  with  greater  satisfaction  to  themselves  when  using  nitrous 
oxid  and  oxygen  for  painful  dental  work  than  without  this  help,  or 
with  only  a  local  anesthetic. 

Obstetrical  Cases. — Guedel  ^  reports  a  number  of  cases  with  ap- 
paratus for  the  self-administration  of  nitrous  oxid  and  air  in  obstet- 
rical cases.  The  analgetic  properties  of  nitrous  oxid  and  oxygen  have 
not  been  tested  in  this  field.  It  would  seem,  however,  to  be  preferable 
to  nitrous  oxid  and  air  by  virtue  of  the  absence  of  the  slightest  asphyxi- 
ation and  the  presence  of  a  more  prolonged  stage  of  analgesia,  the  idea 
being  to  suppress  all  pain  without  completely  subduing  muscular  effort. 
The  nasal  administration,  although  more  wasteful  than  the  usual  method 
of  mask  with  bag,  is  the  most  agreeable  and  most  satisfactory  method 
for  these  cases,  inasmuch  as  it  leaves  the  face  entirely  uncovered.  The 
patient  can  thus  answer  questions,  which  is  sometimes  necessary  in 
order  to  avoid  passing  from  analgesia  to  anesthesia. 

Technique  of  Administration  for  General  Work. — The  mask, 
with  the  cuff  turned  up,  is  placed  upon  the  patient's  face  and  held  in 
Med.  J.,  Oct.,  1911. 


Fig.  59. — Gwathmey-Woolsey  Nitrous  Oxid-Oxygen  Apparatus  as  Used  in  Gen- 
eral Surgery. 


Fig.  60. — Gwathmey-Woolsey   Nitrous  Oxid-Oxygen  Apparatus  in  Adenoid   and 

Tonsil  Operations. 


,  NITROUS    OXID  175 

position  until  unconsciousness  ensues.  The  cuff  is  then  turned  down 
and  fastened  around  the  neck;  it  now  becomes  self-retaining.  If  the 
patient  is  a  vigorous  alcoholic  or  a  nervous  individual,  the  bag  should 
be  partly  filled  with  nitrous  oxid  alone.  When  the  gas  is  turned  on, 
from  two  to  six  breaths,  according  to  the  patient,  should  be  allowed 
through  valves;  the  sliding  cuff  is  then  pulled  out,  and  rebreathing 
instituted,  the  expiratory  valve  being  left  very  slightly  open,  say  one- 
sixteenth  of  an  inch.  As  signs  of  anesthesia  appear,  oxygen  should  be 
allowed  to  bubble  through  in  about  the  proportion  that  will  be  main- 
tained throughout  the  operation.  For  the  first  five  minutes  the  bag 
should  be  slightly  overdistended,  thus  insuring  a  deeper  anesthesia. 
After  that,  seven-eighths  distention  will  meet  all  conditions.  It  is 
unnecessary  to  manipulate  the  valves  after  the  patient  has  been  anes- 
thetized five  minutes,  a  slight  increase  or  decrease  in  the  oxygen,  or  a 
slight  increase  or  decrease  in  the  nitrous  oxid,  according  to  the  re- 
quirements of  the  patient,  being  all  that  is  necessary.  Quite  often  the 
patient  will  continue  to  be  satisfactorily  narcotized  for  ten  or  twenty 
minutes  without  the  supply  valves  being  touched.  Five  mm.  pressure 
will  relax  resistant  patients  sufficiently  for  all  surgical  operations. 

There  is  thus  a  continuous  flow  of  nitrous  oxid  and  oxygen,  with 
continuous  rebreathing.  There  is  slight  escape  of  the  exhalations  at 
all  times.  The  patient's  color  reflex  should  be  maintained,  and  duski- 
ness should  not  be  allowed.  Stertor  should  be  avoided  whenever  possi- 
ble by  the  anesthetist  sustaining  the  lower  jaw  with  the  hand  or  lessen- 
ing the  amount  of  nitrous  oxid. 

To  summarize,  the  advantages  of  the  Gwathmey-Woolsey  apparatus 
are: 

(1)  Absolute  and  perfect  control  of  the  gases  flowing  at  a  low 
pressure. 

(2)  The  gases  are  easily  warmed  whenever  the  patient's  condition 
demands  it. 

(3)  It  is  especially  adaptable  for  endotracheal  anesthesia,  solving 
the  problem  of  the  administration  of  nitrous  oxid  and  oxygen  by  this 
method. 

(4)  Small  amounts  of  ether  can  be  added  whenever  necessary. 

(5)  An  even,  automatic  flow  of  gases,  opening  up  a  new  field  espe- 
cially for  using  the  analgetic  properties  of  the  gases. 

(6)  Small  size  and  portability  of  the  apparatus. 

(7)  The  irritating  impurities  of  the  gases  themselves,  as  well  as 
small  particles  of  rust  from  the  inside  of  the  cylinder,  are  washed  out 
in  the  water  filter  sisrht-feed. 


CHAPTEE   V 

ETHEE 

History  of  the  Use  of  Ether  as  an  Anesthetic. 

Chemistry:  The  Term  Ether;  Properties  of  Ether;  Anesthetic 
Ether ;  Precautions  in  Handling  Ether ;  Sources  of  Impurities  in  Ether ; 
Standards  of  Purity  with  Which  Anesthetic  Ether  Should  Comply; 
Pole  of  Alcohol  in  Ether;  Peroxids;  Aldehyd;  Physiological  Action  of 
the  Impurities  and  Administration  Means  to  Avoid  Them. 

Special  Physiology  :  Effects  Upon  the  Eespiratory  System ;  Ef- 
fects Upon  the  Circulatory  System;  Effects  Upon  the  Nervous  System; 
Effects  Upon  the  Muscular  System ;  Effects  Upon  the  Glandular  System 
and  Other  Structures;  Causes  of  Death  from  the  Administration  of 
Ether;  Stages  of  Ether  Anesthesia;  Elimination;  After-Effects. 

Administration  of  Ether:  The  Open  or  Drop  Method;  The 
Mask;  Ethyl  Chlorid-Ether  Sequence  by  the  Drop  Method;  The  Ethyl 
Chlorid  Ether-Chloroform  Sequence ;  The  Ethyl  Chlorid-Ether  Sequence 
by  the  Closed  Method ;  Chloroform-Ether  Sequence ;  Anesthol ;  Anesthol- 
Ether  Sequence  by  the  Drop  Method;  The  Ether  Rausch;  The  Semi- 
Closed  Method;  Towel  and  Paper  Cones;  The  Handkerchief  Method; 
The  Closed  Method;  The  Nitrous  Oxid-Ether  Sequence;  Technique  of 
the  Nitrous  Oxid-Ether  Sequence;  Nitrous  Oxid-Ether-Chloroform  Se- 
quence ;  The  Vapor  Method  of  Anesthesia ;  Warmed  Ether  Vapor. 

Vapor:  The  Open  Method;  Endopharyngeal  Anesthesia;  Oxygen- 
Ether  Administration;  Concentration  of  Ether  Vapor;  The  Closed 
Method ;  Amount  of  the  Anesthetic  Used ;  Care  of  the  Apparatus ;  Hints ; 
Advantages;  Treatment  of  Accidents. 

Indications  and  Contraindications  of  Ether:  Indications; 
Contraindications, 


HISTORY  OF  THE  USE  OF  ETHER  AS  AN  ANESTHETIC 

In  1795,  ether  was  employed  medicinally  for  the  relief  of  asthma. 
About  this  time  inhalation  therapeutics  seems  to  have  been  a  medical  fad 
for  a  short  period,  and  ether  and  nitrous  oxid  were  used  to  the  exhilarat- 
ing stage  only.     Although  injuries  received  while  under  the  influence 

176 


ETHER  177 

were  not  felt,  no  one  seemed  to  tliijik  of  carrying  the  physiological  effect 
of  the  drug  beyond  what  is  generally  termed  the  second  or  excitement 
stage. 

Twenty-three  years  later,  in  the  English  Quarterly  Journal  of  Sci- 
ence and  Arts,  Faraday  is  stated  to  have  said:  "When  the  vapor 
of  ether  mixed  with  common  air  is  inhaled  it  produces  effects  very 
similar  to  those  occasioned  by  nitrous  oxid.  By  the  imprudent  in- 
spiration of  ether  a  gentleman  was  thrown  into  a  very  lethargic  state, 
which  continued  with  occasional  periods  of  intermission  for  more  than 
thirty  hours."  Teachers,  lecturers,  and  medical  students  had  a  gen- 
eral idea  of  the  physiological  action  of  ether  when  thus  administered, 
and  were  in  the  habit  of  illustrating  lectures  by  allowing  inhalations 
to  continue  until  the  exhilarating  effects  were  produced.  This  con- 
tinued for  the  next  thirty-four  years,  and  ether  frolics  by  students  and 
others  were  indulged  in.  Occasionally,  but  accidentally,  of  course,  the 
third,  or  surgical  stage,  was  reached.  Those  who  sustained  injuries 
in  these  ether  frolics  did  not  complain,  and,  further,  those  who  en- 
tered the  third  or  surgical  stage  of  anesthesia  seemed,  upon  recovery, 
to  have  enjoyed  the  experience  rather  than  otherwise. 

These  two  facts  were  coupled  together  by  Crawford  W.  Long,  of 
Jackson  County,  Georgia,  who  in  1842  (303  years  after  its  discovery 
and  47  years  after  it  was  first  used  medicinally)  administered  ether 
with  the  intention  of  prolonging  surgical  anesthesia  while  performing 
an  operation.  The  anesthesia  and  operation  were  successful,  and  this 
procedure  was  practiced  upon  several  different  occasions  by  him  and 
his  assistants.  Unfortunately  he  took  no  pains  to  acquaint  the  world 
at  large  of  his  discovery  until  Morton  had  successfully  administered  sur- 
gical anesthesia  with  ether  in  the  General  Hospital  of  Massachusetts,  in 
Boston,  four  years  later,  October  17,  1846. 

The  first  operation  with  ether  in  England  occurred  two  months 
later,  on  Dec.  19,  1846,  at  the  house  of  Dr.  Boot,  in  Gower  Street, 
London.  J.  Y.  Simpson,  in  January,  1847,  first  employed  ether  in 
midwifery  practice;  he  discovered  that  the  labor  pains  were  wholly 
abolished,  the  contraction  of  the  uterus  continuing.  Thus  painless  child- 
birth was  produced  for  the  first  time  in  the  world's  history. 

The  physiological  effects  of  different  percentages  of  ether  and  other 
narcotics,  as  determined  by  experiments  on  the  lower  animals,  were 
first  pointed  out  by  John  Snow  in  1858,  and  later  by  J.  T.  Clover. 
Clover  was  also  the  first  to  demonstrate  the  very  great  advantages  of 
the  closed  method  of  air  limitation  and  to  introduce  the  nitrous  oxid- 
ether  sequence. 

The  first  committee  to  attempt  definite  scientific  work  was  ap- 
pointed in  1864,  twenty-two  years  after  ether  was  first  used  as  an  anes- 
thetic. 


178  ANESTHESIA 

Braun,  a  German  physician,  was  the  first  to  modify  the  Junker 
inhaler  into  one  for  giving  ether  as  well  as  chloroform,  either  sepa- 
rately or  in  combination,  and  one  of  the  authors  of  this  book  carried 
this  vaporizing  a  step  further  by  passing  the  vapors  through  hot  water, 
thereby  bringing  them  up  to  the  temperature  of  the  blood,  and  at  the 
same  time  washing  out  various  impurities.  Gwathmey  made  experi- 
ments upon  animals  to  discover  the  difference  between  the  normal,, 
warm  and  cold  vapors  of  ether,  and  also  between  air  and  oxygen  as 
the  vapor  carrier. 

Contemporaneously  with  the  writing  of  this  book  experiments  were 
made  by  the  authors,  who  succeeded  in  masking  the  odor.  (See  Chap- 
ter II,  p.  91.) 

CHEMISTRY 

The  Term  Ether. — Ethers  are  organic  chemical  compounds  of  the 
general  formula  R.  0.  R' ,  where  R,  R'  represent  alkyl  or  aryl  groups. 
Ethers  are  therefore  the  oxids  of  the  alcohol  radicals,  and  may  be  re- 
garded as  anhydrids  of  the  alcohols,  being  formed  by  the  elimination 
of  one  molecule  of  water  from  two  molecules  of  the  alcohols.  They  are 
related  to  the  alcohols  in  the  same  way  as  the  metallic  oxids  are  related 
to  the  metallic  hydroxids. 

Ethers  may  be  simple  or  mixed.^  Simple  ethers  are  the  oxids  of 
monovalent  alkyls;  that  is,  they  contain  two  similar  alcohol  radicals. 
Mixed  ethers  are  those  with  different  radicals  attached  to  the  oxygen 
atom. 

The  term  ether,  as  ordinarily  used,  signifies  diethyl  ether,  ethyl 
ether,  oxid  of  ethyl,  "ethane-oxy-ethane,"  "hydrate  of  ethylene,"  ethylic 
ether,  "hydrate  of  ether,"  "hydric  ether,"  "vinous  ether,"  or  "sulphuric 
ether,"  the  last  two  terms  being  survivals  of  an  earlier  nomenclature. 
The  term  must  not  be  confounded  with  "compound  anesthetic  ether."^ 

Properties  of  Ether* — Pure  ethyl  ether  is  a  colorless,  very  mobile, 
strongly  refractive,  neutral,  inflammable  liquid,  possessing  a  penetrat- 
ing but  exhilarating  odor  and  a  sharp,  burning  taste.  It  has  a  specific 
gravity  of  0.718  —  0.719  at  15/4°,  and  boils  at  +  34.6°  under  760  mm. 
pressure  of  mercury.  By  intense  cooling,  ether  forms  an  ice-like  solid 
which  melts  at  — 117°   C.    (Olszewsky).     It  is  very  volatile,  and,  if 

*  Compound  ethers,  or  more  properly  esters,  are  hydrogen  salts  in  which  the 
typical  acid  hydrogen  has  been  replaced  by  an  alkyl,  and  may  therefore  be  looked 
upon  as  alkyl  salts  of  organic  acids,  since  an  alcohol  and  an  acid  radical  are 
present. 

^  * '  Compound  anesthetic  ether "  is  a  mixture  of  absolute  ethyl  ether  and  amyl 
hydrid  (rhigolene),  proposed  by  Eichardson  for  the  production  of  local  anes- 
thesia by  means  of  cold.  Accidents  have  occurred  as  the  result  of  using  this  mix- 
ture as  an  inhalation  anesthetic. 


ETHER  179 

placed  on  the  skin,  it  evaporates  rapidly,  producing  cold  and  numbness. 
Ether  is  only  slightly  soluble  in  water  (1  in  13  at  -|-  22°  C),  and  it 
dissolves  little  water  (about  1  in  34  at  -j-  22°  C).  It  dissolves  alcohol, 
benzin,  and  chloroform  in  all  proportions.  It  is  a  good  solvent  for 
fats  and  some  resins. 

Anesthetic  Ether. — This  may  contain  ethyl  alcohol  (up  tc  four  per 
cent)  and  traces  of  acetaldehyd,  acids,  and  water,  although,  for  reasons 
given  in  the  text,  the  last  three  mentioned  should  be  entirely  absent. 

Precautions  in  Handling  Ether. — Ether  has  a  high  vapor  tension. 
When  a  vessel  containing  ether  is  left  open  to  the  air,  the  vapor  rises 
sufficiently  to  displace  the  air  or  other  gas  overlying  it,  and  then  flows 
over  the  edge  of  the  containing  vessel.  As  the  vapor  is  very  heavy, 
being  2.6  times  as  heavy  as  the  air,  it  falls  to  the  table,  shelf,  or  floor 
upon  which  the  vessel  rests.  The  vapor  is  very  inflammable,  and,  when 
mixed  with  air,  forms  an  explosive  mixture,  which  is  readily  ignited 
by  a  flame.  Great  care  should  he  taken  to  avoid  using  ether  near  an 
open  flame,  as  a  lighted  gas  jet,  burning  candle,  or  stove,  or  in  the 
neighborhood  of  a  hot  cautery.  A  cautery  should  never  he  used  about 
ihe  mouth  or  nose  when  ether  is  tised  as  the  anesthetic.  Several  cases 
of  severe  burning  have  been  recorded  where  these  precautions  were  not 
taken. 

It  is  important  also  to  take  the  same  precautions  when  pouring 
ether  from  one  vessel  to  another.  The  heavy  vapor  will  travel  some 
distance  along  a  floor,  for  example,  before  being  sufficiently  dissipated 
to  be  free  from  danger.  Where  ether  is  used  with  electric  lights  care 
should  be  taken  that  these  are  not  arc  lights,  and,  if  they  are  incan- 
descent bulbs,  that  there  are  no  short  circuits  or  sparks,  as  the  vapor 
may  be  thus  ignited. 

Sources  of  Impurities  in  Ether. — All  ether  of  anesthetic  grade  is  now 
prepared  from  ethyl  alcohol  and  sulphuric  acid.  The  impurities  to  be 
suspected  are  therefore:  (a)  Those  present  in  the  two  materials  used; 
(b)  those  produced  in  the  process;  (c)  those  developed  during  storage.^ 

It  is  almost  needless  to  call  attention  to  the  necessity  of  having  ethyl 
ether  as  pure  as  human  ingenuity  can  provide  it.  The  methods  used 
for  purification  and  some  of  the  means  of  detecting  impurities  are 
given  in  Appendix  I.  Many  of  the  impurities  are  rarely  found  in 
anesthetic  ether,  as  they  are  removed  in  the  process  of  purification; 
and,  when  some  of  them  are  found,  the  trouble  may  usually  be  traced 
to  substitution,  accidental  or  otherwise,  of  commercial  ether  for  that 
of  anesthetic  grade.  Some  manufacturers  make  anesthetic  ether  only, 
thus  removing  one  source  of  possible  human  error.     As  in  the  case  of 

^  The  elimination  of  all  the  possible  contaminants  of  ethyl  ether,  particularly 
those  usually  present  in  small  amounts,  has  been  discussed  by  Baskerville  and 
Hamor  in  detail;  see  J.  Ind.  Eng.  Cliem.,  3,  302,  307,  309,  316,  380,  391  and  395. 


180  ANESTHESIA 

other  chemicals,  there  are  cases  of  sophistication,  but  these  are  com- 
paratively rare. 

Impukities  from  Materials  Used,  in  Manufacture. — The  sul- 
phuric acid  used  is  of  high  grade,  and  usually  contains  no  impurities 
which  volatilize  with  the  ether.  ^  Eectified  ethyl  alcohol,  95  per  cent, 
with  5  per  cent  water,  is  used.  The  process  of  rectification  of  the  alco- 
hol does  not  always  remove  amyl,  propyl,  or  butyl  compounds,  or  "fusel 
oil,"  and  the  essential  oils  characteristic  of  the  source  of  the  ethyl  alco- 
hol, which  is  commercially  never  free  from  aldehyds  and  traces  of 
acetic  acid.  The  source  of  the  alcohol — that  is,  whether  it  is  made 
from  grain,  molasses,  sawdust,  or  what  not — is  immaterial,  provided 
it  has  been  properly  rectified.  Acetal,  extractive  matter  (from  barrels), 
and  tannic  acid  are  often  present  in  the  alcohol.  Acetone  and  f ormalde- 
hyd  may  also  be  present,  but  are  to  be  suspected  only  when  methylated 
alcohol  is  employed.^  In  the  United  States,  alcohol  denatured  with 
ether  is  now  allowed  in  the  manufacture  of  ether,  so  there  is  little  or  no 
likelihood  of  the  last  mentioned  contaminants.     (See  Appendix  I.) 

Contaminating  By-products  Introduced  by  the  Process. — The 
crude  ether  distillate  resulting  in  the  manufacture  of  ether  by  the  con- 
tinuous process  contains,  together  with  water,  alcohol  and  sulphur  di- 
oxid  ^  as  the  principal  contaminants,  although  small  amounts  of  other 
impurities  (as  fusel  oil,  empyreumatic  oily  matter,  ethyl  acetate,  alde- 
hyd,  acetic  acid,  acetal,  acetone  alone,  or  with  furfurol)  are  generally 
present,  these  varying  with  the  purity^of  the  materials  used  in  the  manu- 
facture and  with  the  care  with  which  the  etherification  is  conducted.* 
These  can  be  and  are  largely  removed  in  the  subsequent  purification. 
Impurities  Developed  in  Storage  of  Ether. — The  standards  laid 
down  by  the  various  pharmacopoeias  of  the  world  are  not  uniform.  This 
is  especially  true  for  ethyl  ether  and  chloroform.  Some  pharmacopoeias 
call  for  an  admixture  of  alcohol.  This  may  come  from  its  retention 
in  the  process  of  manufacture,  or,  as  has  been  recommended,  it  may  be 
added  to  the  rectified  ether  up  to  4  per  cent.  Other  pharmacopoeias 
call  for  an  almost  absolute  ether  (sp.  gr.,  0.720,  15/15°  C).     The  role 

^  Purchasers  of  ether  have  in  the  past  complained  of  ether  which  contained 
sulphuric  acid.  Such  contamination  can  be  due  solely  to  substitution  of  "com- 
mercial" ether. 

'  Guerin  (<7.  Phar.  Chem.,  [7],  4,  492)  reported  that  he  had  detected  acetone 
and  formaldehyd  in  certain  samples  of  anesthetic  ether  on  the  market  in  France 
(Dec,  1911)  ;  and  this  ether  had  evidently  been  prepared  from  alcohol  denatured 
with  methyl  alcohol. 

'  It  should  be  mentioned  that  the  greatest  yield  of  ether  is  obtained  at  140- 
145°  C,  and  that  above  this  temperature  much  sulphur  dioxid  is  evolved. 

^  Patch  (Proc.  Am.  Pharm.  Assn.,  54,  337)  found  that  a  sample  of  ether  sold 
as  90  per  cent  contained  only  74  per  cent;  that  two  samples  of  U.  S.  P.  strength 
possessed  an  acid  reaction  and  yielded  a  residue;  and  one  samplQ  answering  all 
other  tests  gave  a  brown  residue. 


ETHER  181 

of  the  alcohol  will  be  discussed  in  another  paragraph.  If  alcohol  is 
added,  then  the  impurities  present  in  the  alcohol  are  to  be  found  in  the 
ether  supplied,  but,  of  course,  in  correspondingly  smaller  amounts.  As- 
suming that  the  ether  is  prepared  pure  with  the  exception  of  the  vicari- 
ously allowable  percentage  of  alcohol  and  its  usual  five  per  cent  of 
water,  there  are  changes  which  take  place  on  keeping  under  certain 
conditions,  namely,  peroxidation,  with  the  subsequent  formation  of 
acetaldehyd  and  acetic  acid.^ 

Experiences  of  expert  anesthetists,  not  accounted  for  by  idiosyncrasy, 
obtained  in  the  use  of  ethyl  ethers  supplied  by  various  manufacturers 
in  numerous  surgical  cases,  caused  Baskerville  to  carry  out  a  series  of 
elaborate  investigations  on  the  quality  of  the  anesthetics  supplied  by 
various  makers,  and  to  determine  what  changes,  if  any,  occurred  in  the 
drugs  when  kept  under  the  conditions  obtaining  in  everyday  life. 

Standards  of  Purity  with  Which  Anesthetic  Ether  Should  Comply. — 
All  tests  which  have  been  reported  in  the  literature  were  tried  out. 
Many  were  found  to  be  of  no  value  and  some  to  be  misleading.  Some 
pharmacopoeial  tests  are  unnecessarily  rigid;  some  are  open  to  improve- 
ments; others  should  be  replaced  entirely  by  improved  methods  of  de- 
tection; and  several  new  tests  should  be  incorporated  for  detecting  im- 
purities not  considered.  Exhaustive  investigation  into  modes  of  manu- 
facture, validity  of  applicable  chemical  tests,  as  given  in  the  pharma- 
copoeias of  every  civilized  nation,  methods  of  administration,  and  clinical 
experience  warrant  the  assertion  that  ethyl  ether  complying  with  the 
tests  given  in  Appendix  I  for  specific  gravity,  boiling  point,  odor, 
residue,  activity,  aldehyd,  and  peroxids  will  give  the  best  results  by 
whatever  method  the  ether  anesthesia  may  be  induced. 

It  must  be  recognized  that  the  demand  for  a  good  ether  for  anes- 
thesia involves  difficulties  inherent  in  the  practical  application  of  chem- 
ical methods  by  hospitals  and  physicians.  As  stated  in  Appendix  I, 
anesthetic  ether  should  be  provided  in  small  containers,  and  it  is  im- 
practicable, and  should  be  unnecessary,  to  test  the  contents  of  each 
container  before  use;  hence,  reliance  must  be  placed  on  the  experience 
and  integrity  of  the  manufacturer  and  on  the  uniformity  of  his  product. 
We  have  found  that  some  ethers  of  the  market  vary  from  time  to  time, 
not  only  in  specific  gravity  and  absolute  ether  content,  but  also  in  impuri- 
ties. It  is  incumbent  upon  him  who  uses  ether  to  take  proper  precau- 
tions to  prevent  the  development  of  storage  impurities  of  which  the 
manufacturer  may  have  been  innocent. 

Role  of  Alcohol  in  Ether. — For  various  reasons  a  pure  ether  may  be 
mixed  with  ethyl  alcohol  when  it  is  to  be  used  for  anesthesia.  Impuri- 
ties then  observed  may  be  due  in  part  to  the  alcohol  used  in  dilution. 
Practically  all  ethyl  alcohol  contains  some  acetaldehyd. 

^  See  Appendix  I. 


182  ANESTHESIA 

Ethyl  alcohol  serves,  it  is  asserted,  as  a  preservative  for  ether  when 
the  latter  is  properly  stored.  This,  we  believe,  is  without  foundation 
in  fact.  Small  amounts  of  ethyl  alcohol  interfere  in  no  way  with  the 
application  of  ether  in  anesthesia.  However,  the  presence  of  alcohol  is 
unnecessary  except  when  ether  is  administered  by  the  "drop  method." 
In  this  method  the  presence  of  alcohol  prevents  too  rapid  volatilization 
and  consequent  chilling  of  the  mask  with  which  the  ether  is  adminis- 
tered and  the  freezing  of  the  moisture  of  the  breath  or  of  the  air 
therein,  or  the  alcohol  lowers  the  freezing  point  of  the  condensed  water, 
thus  preventing  solidification  of  that  water.  Some  administrators  state 
that  this  freezing  prevents  the  patient  getting  a  full  free  flow  of  the 
vapor.  A  serious  factor  also  is  the  chilling  of  the  lungs  by  the  cold 
vapor.  Davis,  of  the  Johns  Hopkins  Hospital,  has  made  observations 
on  the  temperatures  of  a  number  of  patients  anesthetized  with  ethyl 
ether  by  the  drop  method  and  by  warm  vapors  of  ether.^  In  the  former, 
the  body  temperature  dropped  1°  to  3°  F.,  and  in  the  latter,  not  more 
than  0.3°  F.  in  any  case.  Alcohol  occurring  in  ether  is  subject  to  oxida- 
tion, producing  bodies  in  the  following  order:  alcohol,  aldehyd  (alde- 
hyd  peroxid),  acetic  acid. 

Some  have  maintained  that  pure  ethyl  ether  free  from  alcohol  is 
unsuitable  for  anesthesia,  but  it  is  a  fact  that  the  vapor  from  ether 
containing  alcohol,  when  passed  through  water  at  40°  C,  whereby  the 
alcohol  is  remoyed,  may  be,  and  is  being,  used  with  great  success  for 
anesthesia. 

Peroxids. — Ethyl  ether  of  anesthetic  grade  contains  peroxidized 
compounds  after  exposure  to  atmospheric  oxygen  for  considerable 
periods  of  time,  especially  when  it  is  stored  in  colorless  glass  vessels 
or  in  badly-stoppered  tin  containers.  The  latter  is  an  unfortunately  com- 
mon practice  in  some  hospitals.  The  extent  of  the  oxidation  is  de- 
pendent upon  the  purity  of  the  sample,  the  amount  of  air  present,  the 
nature  of  the  container,  the  temperature  conditions,  and,  in  the  case 
of  glass  vessels,  the  intensity  of  the  light,  which  accelerates  the  oxida- 
tion.^ 

^Discussed  in  Appendix  I.  in  detail. 

'  Baskerville  and  Hamor  made  the  following  experiments : 

Ether  was  allowed  to  stand  for  200  days  in  150-c.c.  tin  containers,  partly 
filled,  stoppered  as  well  as  the  mouth  of  the  containers  would  permit,  and  ex- 
posed to  varying  temperature  conditions  inside  of  a  window  with  southern  ex- 
posure. The  conditions  of  storage  were  similar  to  those  which  obtain  in  many 
laboratories  and  hospitals.  None  of  the  samples  so  exposed  exhibited  a  peroxid 
reaction  originally,  but  all  contained  small  amounts  of  water  and  alcohol.  The 
following  results  were  obtained,  using  the  vanadic  acid  and  cadmium  potassium 
iodid  tests: 

No.  lA  (container  one-fifth  full)  :    strong  peroxid  reaction;  strongly  acid. 

_Vo.  IB  (container  one-half  full)  :  marked  peroxid  reaction,  but  less  pro- 
nounced than  in  No.  lA;  strongly  acid.     {Continued  on  p.  183.) 


ETHER  183 

Aldehyd. — Acetaldehyd  is  undoubtedly  the  commonest  and  most 
objectionable  contaminant  of  anesthetic  ethers^  and  its  presence  may 
account  for  some  of  the  observations  made  in  practice.^  Several  have 
found  occasion  to  emphasize  the  objectionable  presence  of  aldehyd  in 
many  ethers  on  the  market.^  It  is  one  of  the  impurities  most  likely  to 
be  generated  by  exposing  partially  filled  containers  to  varying  at- 
mospheric conditions  for  long  periods  of  time.  Ether  should  not  be 
stored  in  glass  vessels  for  any  length  of  time  without  being  tested  for 
oxidation  products  before  use,  and  the  tin  containers  should  be  of  such 
capacity  that  they  need  not  be  opened  without  being  soon  emptied. 
Any  remnants  in  these  containers,  especially  if  they  have  been  kept 
for  some  time,  should  not  be  used  for  anesthesia  without  purification. 
The  careless  practice  observed  in  some  large  hospitals  where  the  operat- 
ing rooms  are  in  more  or  less  continuous  service  is  to  be  looked  upon 
with  disapproval.  The  using  of  large  containers  of  ether  or  chloroform, 
and  placing  them  on  a  shelf  where  the  drug  is  subjected  to  the  condi- 
tions referred  to,  shoiild  not  be  countenanced  by  those  in  authority.  It 
can  scarcely  be  defended  on  the  score  of  expense,  as  the  cost  of  the 
anesthetic  of  this  nature  used  in  an  operation  is  trifling  in  comparison 
with  the  other  costs  involved,  and  should  not  be  counted  when  not  only 
the  comfort  but  the  safety  of  the  patient  is  taken  into  consideration. 

Physiological  Action  of  the  Impurities  and  Administration  Means 
to  Avoid  Them. — Since  it  is  highly  important  that  ether  intended  for 
(Continued  from  p.  182.) 

No.  ]C  (container  four-fifths  full)  :    very  faint  peroxid  reaction. 

No.  2A  (container  two-thirds  full)  :  no  peroxids  present.  This  container 
was  provided  with  a  tightly  fitting  stopper.  The  neck  of  the  can  was  cylindrical, 
whereas  those  holding  the  preceding  were  provided  with  a  conical  neck,  and  it 
was  thus  possible  to  cork  the  can  more  securely. 

No.  2B  (one-half  full)  :  no  peroxids  present.  This  sample  was  stoppered 
similarly  to  No.  2 A. 

No.  3 A  (one-tenth  full)  :    strong  peroxid  reaction. 

No.  3B  (one-third  full)  :  no  peroxids  present.  This  container  was  properly 
stoppered. 

No.  3G  (three-fourths  full)  :  no  peroxids  present.  Container  was  well  stop- 
pered. 

No.  3D  (four-fifths  full)  :  no  peroxids  present.  Container  was  properly 
stoppered. 

Walton  {Can.  Drug.,  23,  584)  has  reported  that  one  out  of  eight  samples 
of  commercial  ether  examined  contained  hydrogen  dioxid. 

^  Acetaldehyd  vapor,  when  inhaled,  produces  asphyxia.  Prolonged  exposure 
to  light  and  air  gives  rise  to  aldehyd  in  ether,  and  such  treatment  greatly 
affects  the  results  of  etherization.  In  one  case  of  which  we  have  record,  a  sam- 
ple of  ether  which  induced  irritation  of  the  respiratory  tract  during  etherization 
was  examined,  and  the  only  impurity  found  was  acetaldehyd. 

'■"  Thoms:  Pharm.  Ztg.,  1894,  777;  Warden:  Pharm.  J.  and  Trans.,  1885, 
521;  Am.  J.  Pharm.,  57,  148;  and  Graham:  Proc.  Penn.  Pharm.  Assn.,  1906, 
153. 


184  ANESTHESIA 

anesthetic  purposes  should  be  carefully  manufactured  and  properly 
stored,  as  prolonged  exposure  to  light  and  air  produces  aldehyd  and 
acetic  acid,  which  greatly  afPect  the  results  of  etherization,  causing  cough- 
ing, suffocation,  and  even  dangerous  after-effects,  such  ether  should  al- 
ways be  tested  for  peroxids  and  aldehyd,  and  the  presence  of  the  latter 
should  be  rigorously  guarded  against,  especially  if  the  ether  is  to  be 
administered  by  the  drop  method;  or  the  ether,  if  so  contaminated, 
should  be  administered  by  a  method  which  eliminates  these  impurities 
before  it  is  introduced  into  the  animal  system.  This  is  accomplished  by 
the  Gwathmey  method,  as  experimentally  determined  by  Baskerville. 
Anesthetic  ethers  known  to  contain  minimum  amounts  of  aldehyd, 
ether  known  to  contain  excessive  amounts  (both  offered  on  the  market), 
and  ether  to  which  still  larger  amounts  of  aldehyd  were  added,  were 
placed  in  the  Gwathmey  apparatus  and  severally  operated  as  in  prac- 
tice, except  that  the  vaporized  ether,  which  the  patient  would  have  got, 
was  condensed  and  examined.  The  aldehyd,  acetic  acid,  and  alcohol 
accumulated  in  the  water,  and  the  condensed  ether  (which  the  patient 
breathed)  was  free  from  the  aldehyd  and  acetic  acid,  as  shown  by  the 
most  rigorous  application  of  the  tests  recommended  for  their  detection. 
(See  p.  864.) 


SPECIAL   PHYSIOLOGY 

The  various  factors  which  have  been  mentioned  as  exercising  a  modi- 
fying influence  upon  the  physiological  action  of  inhalation  anesthetics 
in  general  are  notably  potent  with  reference  to  ether.  Inasmuch  as  this 
agent  is  more  commonly  employed  for  general  surgical  purposes  than 
any  of  the  others,  the  effects  of  these  modifying  factors  have  been  given 
most  attention  in  the  administration  of  ether.  In  the  present  stage  of 
the  development  of  this  branch  of  surgery  it  is  the  exception  rather 
than  the  rule  to  find  an  anesthetist  giving  ether  alone,  without  the 
utilization  of  one  or  all  of  the  modifying  factors  discussed  under  Gen- 
eral Physiology.  (See  p.  30.)  It  is  to  be  borne  in  mind,  however, 
that  the  following  consideration  of  the  physiological  effects  of  ether 
involves  the  administration  of  this  agent  without  reference  to  sequence 
with  other  agents  or  to  adjuvant  medication^  and  without  the  utilization 
of  other  factors  previously  mentioned. 

With  ether,  no  less  than  with  chloroform  and  the  other  inhalation 
anesthetics,  the  discussion  of  its  effects  upon  specific  parts  of  the 
organism  is  purely  arbitrary,  and  is  resorted  to  for  purposes  of  con- 
venience. It  is  to  be  borne  in  mind  that  this  agent  presents  no  excep- 
tion to  the  general  rule  of  the  correlation  of  effects. 

For  a  discussion  of  the  course  of  ether  anesthesia  when  all  the  modi- 


ETHER  185 

fying  factors  are  considered,  according  to  the  most  advanced  technique, 
the  reader  is  referred  to  Chapter  VIII. 

Effects  Upon  the  Respiratory  System.-^It  is  unequivocably  agreed 
that  ether  has  a  powerful  stimulating  effect  upon  the  respiratory  sys- 
tem during  the  earlier  stages  of  its  administration,  as  evidenced  by  the 
increased  rate  of  respiration.  As  the  administration  proceeds,  how- 
ever, the  direct  action  of  the  agent  upon  the  respiratory  center  causes 
a  slowing  of  the  respiratory  movements  and  a  decrease  in  their  depth, 
with  final  complete  cessation  of  respiration,  in  consequence  of  paralysis 
of  the  center,  as  the  administration  is  carried  beyond  the  limits  of 
safety.  The  rate,  depth,  and  stertor  of  respiration  thus  become  the 
safest  guides  as  to  the  degree  of  anesthesia,  as  will  be  seen  when  the 
stages  are  discussed. 

The  respiratory  system  is  affected  before  the  circulatory,  and  for 
this  reason  it  is  possible  to  resuscitate  the  subject  when  respiration 
temporarily  ceases  from  other  causes  than  paralysis  of  the  respiratory 
center. 

Ether  exercises  a  pronounced  irritating  effect  upon  the  air  passages, 
which  gives  rise  to  a  free  secretion  of  mucus. 

For  further  details  of  the  effects  of  ether  upon  the  respiratory  sys- 
tem the  reader  is  referred  to  Anesthesia,  p.  247. 

Effects  Upon  the  Circulatory  System. — The  effect  of  ether  upon  the 
Hood  has  been  made  the  subject  of  a  large  part  of  the  experimental 
investigation  of  the  physiological  action  of  this  agent. 

Engelhardt,^  in  his  experimental  study  of  ether  narcosis,  was  ena- 
bled to  establish  strictly  definite  relations  between  the  concentration  of 
the  narcotic  agent  and  the  temperature  of  the  vehicle  in  the  effect  of 
disintegration  on  human  and  animal  red  blood  corpuscles.  In  these 
experiments  9.4  per  cent  sucrose  solutions  and  salt  solutions,  such  as 
0.9  per  cent  sodium  chlorid  and  5.5  per  cent  magnesium  sulphate  solu- 
tions, were  mixed  with  known  quantities  of  ether.  The  higher  the  con- 
centration of  the  narcotic  agent,  the  lower  the  temperature  at  which 
the  red  blood  cells  were  dissolved;  vice  versa,  the  weaker  the  concentra- 
tion, the  higher  the  temperature  limit  at  which  hemolysis  took  place. 
In  animals,  as  well  as  in  man,  the  disintegration-point  corpuscles — i.  e., 
the  temperature  at  which  the  fluid  changed  its  color  through  the  break- 
ing down  of  the  theoretical  corpuscular  sheath  and  the  escape  of  hemo- 
globin— was  lowered  by  several  degrees,  after  prolonged  narcosis,  with 
indifferent  salt  solutions.  In  the  case  of  salt  solutions  containing  ether, 
on  the  other  hand,  the  red  blood  corpuscles  which  had  been  removed 
from  the  animal  body  during  or  after  the  narcosis  were  dissolved  only 
at  a  higher  temperature.     In  other  words,  the  resistance  of  the  red 

^  Engelhardt :  ' '  Neue  Gesichtspunkte  in  der  Beurteilung  der  Aethernaxkose, ' ' 
Mitt.  a.  d.  Grenzgeb.  d.  Med.  u.  Chir.,  IS,  1903-1904. 


186  ANESTHESIA 

blood  corpuscles  against  the  narcotic  agent  was  increased.  Briefly, 
the  red  blood  corpuscles  of  etherized  animals,  according  to  Engelhardt, 
have  a  lower  "melting  point"  in  indifferent  salt  solutions,  whereas  the 
"melting  point"  of  the  narcotized  erythrocytes  is  increased  in  salt  solu- 
tions which  -contain  ether.  The  explanation  for  this  increased  resist- 
ance has  not  yet  been  discovered. 

In  his  experimental  investigations  on  the  appearance  of  intravital 
coagulation  and  thrombosis  in  the  vessels  of  internal  organs  after  ether 
narcosis,  Mulzer  ^  was  enabled  to  demonstrate  a  disintegrating  effect 
of  the  ether  vapors  upon  the  cells.  The  primary  factor  consists  in  an 
injury  of  the  red  blood  corpuscles  through  the  anesthetic  agent,  which 
leads  secondarily  to  agglutination  and  coagulation,  with  formation,  or 
excretion,  of  fibrin. 

With  special  reference  to  ether,  twenty-five  healthy  animals,  mostly 
rabbits,  were  anesthetized  so  deeply  with  ether  such  as  is  used  for  nar- 
cosis that  the  corneal  reflexes  were  lost  during  the  entire  duration  of 
the  experiment.  Some  animals  died  during  the  narcosis,  while 
others  were  subjected  to  vivisection,  under  deep  narcosis,  at  the  end  of 
a  definite  period,  and  fresh  specimens  of  their  organs  were  prepared. 
In  seven  animals,  which  survived  at  most  half  an  hour  in  the  narcosis, 
nothing  pathological  was  found,  and  the  vessels  contained  only  normal, 
undeformed,  well-stained  blood  corpuscles.  When  the  narcosis  even 
slightly  exceeded  half  an  hour,  more  or  less  numerous  blue-stained 
granules  were  found  within  the  vascular  lumina,  especially  in  the  sub- 
pleural  small  vessels  of  the  lung,  attached  to  the  vascular  walls.  The 
red  cells  in  the  vascular  lumen  were,  for  the  most  part,  perfectly 
normal  only  in  the  center,  but  deformed,  granular,  and  disintegrated 
toward  the  vascular  wall.  In  case  the  narcosis  could  be  continued  for 
three-quarters  of  an  hour  to  one  hour,  there  appeared  fine  blue  threads, 
radiating  from  the  blue  granules  or  passing  between  them  into  the 
layer  of  the  deformed  red  blood  corpuscles.  After  a  still  longer  dura- 
tion of  the  narcosis  the  contents  of  certain  vessels  were  seen  to  be  dis- 
tinctly arranged  after  the  fashion  of  typical  thrombi,  granular-fibrillar 
masses  alternating  with  layers  of  deformed  or  normal  erythrocytes.  In- 
dividual lumina  of  small  vessels  were  entirely  filled  with  granular  and 
fibrillar  masses,  between  which  lay  only  some  masses  of  reddish  detritus, 
but  no  normal  blood  corpuscles.  Occasionally  distinct  granules  and  very 
delicate  threads  could  also  be  demonstrated  in  the  capillaries  of  the 
pulmonary  alveoli.  Although  these  processes  occurred  chiefly  in  the 
finer  vessels  of  the  lung,  they  were  also  observed,  although  to  a  less 
marked  extent,  in  the  vessels  of  the  liver  and  the  kidneys. 

^Mulzer:  "Das  Auftreten  intravitaler  Gerimmungen  und  Thrombose  in  den 
Gefassen  innerer  Organe  nach  Aether  und  Chloroform  Narkosen,"  Munch,  med. 
WocK,  1907,  No.  9,  408. 


ETHER  187 

These  blue-stained  granular  and  fibrillar  masses  are  regarded  by 
Mulzer  as  granular  and  fibrillar  fibrin.  As  the  primary  factor,  he  as- 
sumes a  lesion  of  the  red  blood  corpuscles  through  the  circulating  ether, 
which  acts  as  a  blood  poison.  This  leads  secondarily,  favored  by  a 
variety  of  other  causes,  to  agglutination  and  coagulation,  with  forma- 
tion, or  excretion,  respectively,  of  fibrin.  The  number  of  the  red  blood 
corpuscles  is  very  considerably  diminished,  after  the  narcosis,  and  the 
changes  in  the  configuration  of  the  erythrocytes  plainly  indicate  the 
destructive  influence  of  the  narcotic  agent. 

Bloch/  who  investigated  the  effects  of  ether  upon  the  hemoglobin 
and  the  red  blood  corpuscles  during  ether  narcosis  in  man  and  in  rab- 
bits, considers  it  as  certain  that  any  narcosis  causes  an  organic  change 
of  a  certain  number  of  red  blood  cells  in  consequence  of  the  chemical 
absorption  of  the  anesthetic  agent  into  the  blood.  Provided  the  operative 
intervention  is  not  too  long  and  is  conducted  under  proper  concentra- 
tion of  the  ether  vapor,  without  too  great  a  difl'erence  in  temperature 
at  the  surface  of  the  lung,  the  lesion  does  not  exceed  the  degree  of  a 
"physiological"  injury  of  the  erythrocytes.  Otherwise  the  hemoglobin 
escapes  entirely  from  the  red  cells  under  disintegration  of  the  cellular 
lecithin  sheath,  only  the  stroma  remaining  behind;  or  the  hemoglobin 
may  escape  in  part,  rendering  hemoglobin  debris  of  various  forms  visible. 
These  erythrocyte  ruins  are  retained  in  the  liver,  spleen,  and  other 
organs,  and  are  in  part  utilized  again.  The  lost  blood  corpuscles  are 
replaced  by  compensatory  function  of  the  bone  marrow,  from  which 
new  erythrocytes  pass  into  the  blood,  according  to  Bloch,  whose  state- 
ments are  based  upon  the  counting  of  the  blood  corpuscles  and  the  de- 
termination of  the  hemoglobin. 

In  an  experiment  upon  a  rabbit  blood  corpuscles  with  polychroma- 
tophile  degeneration,  microcytes,  macrocytes,  masses  of  stellate  figures, 
etc.,  were  found  by  means  of  Jenner's  blood  stain,  so  that  Bloch  does 
not  regard  it  as  altogether  impossible  that  ether  narcosis  may  ultimately 
produce  the  blood  picture  of  pernicious  anemia. 

As  the  most  tangible  evidence  of  the  destructive  power  of  ether  upon 
the  blood,  hemorrhagic  transudates  into  the  body  cavities  were  found 
in  animals  which  had  been  killed  by  the  narcosis.  Individual  differences, 
as  emphasized  by  Bloch,  must  be  assumed  to  exist  in  different  animal 
species,  and  even  in  different  animals  of  the  same  species. 

Stursberg  ^  studied  the  behavior  of  the  blood  pressure,  under  the 
*  Bloch :      ' '  Neuere    Untersuchungen    iiber    die    Einwirkung    von    Aether    auf 
Haemoglobin  und  rote  Blutkorperehen  wahrend  der  Narkose  an  Menschen  und  an 
Kaninchen,"  Beut.  Ztschr.  f.  Chir.,  1909,  97,  132. 

'Stursberg:  "  Ueber  das  Verhalten  des  Blutdrucks  unter  der  Einwirksung 
von  Temperatureizen  in  Aether  und  Chloroform  Narkose  und  seine  Bedeutung  fiir 
Entstehung  der  Nachkrankheiten. "  Mitt.  a.  d.  Grensgeb.  d.  Med.  u.  Chir.,  1911, 
S2,  1. 


188  ANESTHESIA 

action  of  temperature  stimuli,  in  ether  narcosis,  as  well  as  its  bearing 
on  the  origin  of  post-anesthetic  diseases.  He  found  that  the  action  of 
cold  upon  the  skin  is  followed  by  a  contraction  of  the  peripheral  arteries, 
and  hence  a  rise  of  blood  pressure  with  increased  blood  supply  to  the 
internal  organs.  This  behavior  of  the  vascular  reflexes,  in  his  opinion, 
certainly  plays  an  important  part  in  the  origin  of  diseases  due  to  catch- 
ing cold.  He  investigated  the  behavior  of  dogs  in  ether  narcosis  under 
the  action  of  cold  produced  by  plunging  the  animal  into  a  cold  bath.  It 
was  found  that  in  ether  narcosis  this  vascular  reflex  behaved  as  in  un- 
narcotized  animals.  In  chloroform  narcosis,  on  the  other  hand,  the 
refrigeration  of  the  skin  is  not  followed  by  extensive  vascular  contrac- 
tion with  hyperemia  of  internal  organs.  Ether  narcosis,  therefore,  in- 
volves certain  conditions  for  after-diseases  due  to  cold  which  do  not 
exist  in  chloroform  narcosis.  Accordingly  any  chilling  of  the  skin  is 
to  be  carefully  avoided  in  ether  anesthesia. 

Ether  acts  as  a  direct  heart  stimulant  during  the  early  stages  of  its 
administration,  and  when,  during  the  course  of  deeper  narcosis,  the 
subject  is  allowed  to  return  to  a  lighter  degree,  the  pulse  is  accelerated, 
and  blood  pressure  is  slightly  raised  or  remains  constant.  Ether  be- 
comes a  cardiac  depressant  only  in  the  later  stages  of  anesthesia,  or 
when  a  toxic  amount  is  employed.  Because  of  its  depressing  effect, 
under  these  circumstances,  upon  the  vasomotor  center,  there  is  general 
arterial  dilatation,  with  slowing  of  the  pulse  and  a  slight  fall  of  blood 
pressure.  In  fatal  cases  of  ether  toxemia  cardiac  failure  follows  failure 
of  respiration. 

While  the  circulation  may  be  stimulated  or  depressed  by  surgical 
shock  or  other  means,  in  the  vast  majority  of  cases  of  ether  anesthesia 
it  is  dependent  upon  the  respiration.  Blood  pressure  is  maintained  at 
the  highest  level  during  full  surgical  anesthesia  by  giving  the  smallest 
dose  possible  to  obtain  this  state.  An  overdose  of  the  anesthetic,  or  an 
obstruction  in  the  airway,  rapidly  increases  shock,  with  consequent  fall 
of  blood  pressure  and  with  rapid  and  feeble  pulse.  While  the  heart  may 
be  arrested  in  diastole  by  ether,  a  fatal  case  of  reflex  inhibitory  arrest 
has  never  been  reported.  The  circulation  is  immediately  affected  by  the 
handling  of  important  nerves  and  blood  vessels,  but  the  heart  usually 
resumes  the  normal  rhythm  as  soon  as  this  ceases.  The  auricles,  as  a 
rule,  are  more  affected  than  are  the  ventricles,  as  indicated  by  a  weak- 
ened auricular  contraction  and  increased  ventricular  relaxation. 

Effects  TJpon  the  Nervous  System. — The  first  effect  of  ether  upon  the 
nervous  system  is  one  of  stimulation.  Like  chloroform,  however,  with 
increasing  dosage,  it  produces  progressive  paralysis  of  the  central  nerv- 
ous system,  the  phenomena  affecting  the  centers  in  the  following  order: 

(1)  The  higher  cerebral  centers,  involving  the  intellectual  faculties; 

(2)  The  lower  cerebral  centers,  involving  sensation  and  motion ; 


ETHER  189 

(3)  The  spinal  cord,  involving  sensation  and  motion; 

(4)  The  medullary  centers,  involving  vital  function. 

Sensation  is  not  lost  with  equal  rapidity  throughout  the  hody,  the 
back  and  the  extremities  being  involved  first,  the  genital  organs  and 
rectum  next,  and  the  parts  supplied  by  the  trigeminus  last. 

The  effects  of  ether  upon  the  nervous  system,  as  observed  clinically, 
are  given  under  the  Stages  of  Anesthesia. 

Effects  Upon  the  Muscular  System. — During  the  early  administration 
of  ether,  when  the  stimulating  action  of  the  agent  is  generally  mani- 
fest, the  muscular  system  is  affected  no  less  than  other  parts  of  the 
organism.  The  entire  muscular  system  may  be  thrown  into  a  state  of 
tonic  contraction,  or,  as  pointed  out  by  Hewitt,^  there  may  occur  a 
fine  tremor,  designated  as  the  "ether  tremor."  As  the  administration 
proceeds,  general  muscular  relaxation  ensues.  It  is  to  be  borne  in  mind, 
however,  that  spasm  of  various  parts  of  the  muscular  system,  particu- 
larly of  the  masseter,  the  tongue,  the  laryngeal  muscles,  the  muscles  of 
the  neck,  chest,  and  abdomen,  may  occur  during  the  course  of  ether 
anesthesia,  giving  rise  to  respiratory  embarrassment  and  other  compli- 
cations. 

The  clinical  significance  of  the  effects  of  ether  upon  the  muscular 
system  is  considered  under  Stages  of  Anesthesia. 

Effects  XTpon  the  Glandular  System  and  Other  Structures. — The  ac- 
tion of  ether  upon  the  glandular  system  is  of  clinical  importance  with 
reference  to  the  course  of  the  administration,  but  particularly  with 
regard  to  the  influence  upon  the  after-effects.  Because  of  the  stimulat- 
ing and  irritating  effects  of  ether  upon  the  mucous  membranes  of  the 
upper  air  passages,  trachea  and  bronchi,  there  is  always  a  hypersecretion 
of  mucus,  which,  in  some  instances,  amounts  to  what  has  been  called 
mucus-inundation.  This  may  give  rise  to  fatal  asphyxia,  and  is  pre- 
sumably one  of  the  causes  of  post-anesthetic  bronchitis  and  pneu- 
monia. 

The  irritating  effect  of  ether  affects  the  salivary  glands,  giving  rise 
to  an  excessive  secretion  of  the  fluid.  When  this  is  swallowed,  post-anes- 
thetic vomiting  is  apt  to  occur.  Coincidentally  with  hyperactivity  of  the 
mucous  glands  of  the  respiratory  tract  and  of  the  salivary  glands,  there 
is  apt  to  be  overactivity  of  the  mucous  glands  of  the  stomach  and  intes- 
tines, causing  retching  and  vomiting  during  and  after  the  administra- 
tion. 

The  action  of  ether  upon  the  liver  and  kidneys  has  called  forth  con- 
siderable investigation,  both  clinical  and  experimental. 

Grondahl,^  studying  the  effects  upon  the  kidneys,  found,  in  75  ether 

^Hewitt:     " Ansestlieties, "  363   (1912). 

^  Grondahl :  '  *  Wirkung  der  Aethernarkose  auf  die  Nieren, ' '  Norsk  Magazin 
for  Laegevidenskdben,  1905,  No.  5;  Beut.  wed.  Woch.,  1905,  No.  25,  1005. 


190  ANESTHESIA 

narcoses,  where  the  urine  had  been  examined  before  the  narcosis,  albu- 
min present  in  27  cases  (36  per  cent),  alwaj's  associated  with  cylin- 
ders, excepting  in  three  instances.  The  albumin  frequently  did  not 
appear  until  the  second  day,  and  promptly  subsided  in  the  major- 
ity of  the  cases.  The  high  percentage  of  albuminuria  is  referred  by 
Grondahl  to  the  fact  that,  in  general,  these  patients  had  undergone 
severe  and  prolonged  operations.  Albuminuria  appeared  at  the  end  of 
the  first  day  in  20  per  cent  of  the  cases,  and,  at  the  end  of  the  second 
day,  in  16  per  cent.  The  average  duration  of  the  albuminuria  was  from 
seven  to  nine  days.  It  was  influenced  by  the  age  of  the  patients,  the  time 
of  the  operation,  and  the  amount  of  ether  used.  In  case  of  repeated  nar- 
cosis the  albuminuria  appeared  after  each  narcosis,  but  with  diminishing 
severity.  Ether  accordingly,  in  Grondahl's  opinion,  does  not  cause  an 
intoxication-nephritis. 

According  to  Rathery  and  Saison,^  ether  inhalation,  single  or 
repeated,  is  capable  of  producing  certain  lesions  of  the  liver  and  the 
kidneys  in  rabbits,  although  by  no  means  invariably.  The  renal  lesions 
are  less  frequent  and  less  severe  than  in  the  corresponding  experiments 
with  chloroform.  The  liver,  on  the  other  hand,  seems  to  be  even  more 
sensitive  toward  ether  than  toward  chloroform,  for  it  is  often  changed 
more  seriously  after  ether  inhalation. 

Thompson  ^  summarizes  his  observations  upon  the  effects  of  ether 
upon  renal  activity  as  follows : 

"(1)  During  ether  narcosis  the  volume  of  urine  secreted  is  affected  in 
two  ways.  In  the  majority  of  experiments  there  is  a  decrease,  in  a  few 
an  increase.  The  latter  is  probably  an  early  or  light  effect,  the  former 
a  pronounced  effect.  The  depressing  effect  is,  however,  more  marked 
than  with  chloroform,  and  complete  arrest  occurs  more  readily. 

"(2)  The  after-effect  is  less  marked  but  similar  to  that  of  chloro- 
form. The  maximum  outflow  of  urine  occurs  about  three  hours  after 
removal  of  the  anesthetic. 

"(3)  The  output  of  nitrogen  with  ether  corresponds  more  closely 
with  its  influence  on  the  outflow  of  urine  than  is  the  case  with  chloro- 
form. In  the  later  stages  of  the  anesthesia,  where  the  urine  volume  is 
decreased,  the  excretion  of  nitrogen  is  diminished  almost  exactly  to  the 
same  degree  as  the  urine  volume.  In  the  group  of  catheter  experiments 
the  excretion  of  nitrogen  fell  to  26,03  per  cent,  the  quality  of  urine  to 
25.4  per  cent  of  the  normal  amount. 

"(4)   The  effect  of  ether  narcosis  on  the  circulation  of  the  urine  dif- 

^  Rathery,  F.,  and  Saison,  M. :  "  Lesions  experimentales  du  foie  at  du  rein 
a  la  suite  d 'inhalation  d 'ether  au  lapin, "  Compt.  rend.  Soc.  de.  hiol.,  L.  18,  5, 
211    (1910). 

^  Thompson,  W.  H. :  "  Anaesthetics  and  Renal  Activity, ' '  Brit.  Med.  J., 
March  17,  1906. 


ETHER  191 

fers  also  from  that  of  chloroform.  With  the  former  the  urine,  when 
diminished  in  volume  is,  as  a  rule,  more  concentrated  (contains  more 
nitrogen).  The  converse  was  the  case  with  chloroform.  The  effect  of 
ether  is  therefore  primarily  vascular. 

"(5)  In  ether  narcosis,  when  the  curves  of  urine  outflow,  kidney  vol- 
ume, and  blood  pressure  are  compared,  although  there  is  not  complete 
parallelism,  there  is,  on  the  whole,  a  closer  correspondence  than  is  the 
case  with  chloroform.  This  statement  does  not  apply  to  the  arrest  of 
urinary  secretion,  which  occurs  more  readily,  and  with  a  relatively  higher 
blood  pressure,  in  ether  than  in  chloroform  narcosis. 

"(6)  The  escape  of  leucocytes  into  the  urine,  after  full  ether  nar- 
cosis, is  more  marked  than  with  chloroform,  probably  indicating  a  higher 
degree  of  stasis  in  the  glandular  capillaries.  Dilatation  of  capillaries 
and  escape  of  leucocytes  have  been  noted  by  previous  investigators,  after 
ether  inhibition,  in  the  case  of  other  vascular  areas  than  renal. 

"(7)  An  increased  excretion  of  chlorids  is  seen  after  ether  inhala- 
tion, but  is  much  less,  and  of  shorter  duration,  than  in  the  case  of 
chloroform. 

.  "(8)  Temporary  albuminuria  appears  in  dogs  in  a  much  larger  pro- 
portion of  experiments  with  ether  than  with  chloroform. 

"(9)  Keducing  substances,  not  sugar,  which  were  not  present  in  the 
normal  urine,  appeared  in  a  small  number  of  the  experiments  after  ether 
narcosis." 

From  experiments  upon  dogs,  G^ube  ^  attributes  the  glycosuria  ob- 
served during  ether  narcosis  to  a  disturbance  of  the  heat  regulation  of 
the  organism.  He  is  of  the  opinion  that  the  reduction  in  temperature 
is  produced  by  the  radiation  from  the  skin,  as  a  result  of  the  vasodilata- 
tion caused  by  the  ether. 

Nicloux  2  conducted  an  interesting  series  of  experiments  upon  guinea 
pigs  with  reference  to  the  passage  of  ether  from  the  mother  to  the  fetus. 
The  following  conclusions  were  arrived  at:  The  ether  passes  from  the 
mother  to  the  fetus;  the  fetal  liver  contains  more  ether  than  the  mater- 
nal liver,  presumably  due  to  the  relative  richness  of  the  former  in  leci- 
thin. Chloroform  shows  exactly  the  same  behavior.  This  transition  is 
in  every  way  comparable  to  the  behavior  of  alcoholic  substances,  which 
involve  the  blood  corpuscles  and  the  plasm  in  the  same  proportion.  • 
ISTicloux  3  was  also  able  to  demonstrate  the  passage  of  considerable  quan- 
tities of  ether  into  the  milJc  in  ether  narcosis.  The  animal  serving  for 
these  experiments  was  a  goat.    The  cause  is  referred  by  ISTicloux  to  the 

'Grube:     Arch.  ges.  Physiol.,  138,  601. 

*  Nicloux,  M. :  "  Passage  de  1  'ether  de  la  mere  au  foetus, ' '  Compt.  rend. 
Soc.  de  biol,  1908,  64. 

^Nicloux:  "Passage  de  1 'ether  dans  le  lait, "  Compt.  rend.  Soc.  de  hiol.,  1908, 
64. 


192  ANESTHESIA 

affinity  of  ether  for  fats.  Analogous  investigations  have  shown  the 
passage  of  chloroform  into  the  milk, 

Fabre  and  Verrier  ^  report,  as  contributions  to  the  knowledge  of 
the  influence  of  ether  narcosis  upon  the  lactation,  two  observations  upon 
nursing  mothers,  who  were  put  under  ether  for  the  performance  of  minor 
operations  (ruptured  perineum  and  anal  fissure).  The  secretion  of  milk 
was  in  no  way  modified  in  these  two  cases,  and  the  infants  were  put  to 
the  breast  on  the  day  of  the  operation  without  untoward  results. 

In  the  discussion  of  these  observations  Eaucher  stated  that  in  his 
experience  with  several  cases  the  action  of  the  anesthetic  on  the  secretion 
of  milk  was  always  negative.  There  is,  accordingly,  no  reason  to  put  off 
a  necessary  operation  on  a  nursing  mother.  The  child  is  not  usually  put 
to  the  breast  on  the  day  of  the  operation,  but  more  to  let  the  patient  rest 
than  for  fear  of  a  secretion  of  inferior  milk.  On  the  following  day  the 
nursing  may  be  resumed. 

Causes  of  Death  from  the  Administration  of  Ether. — Because  of  the 
relative  safety  of  ether,  the  causes  of  death  from  its  administration  have 
not  been  made  the  subject  of  such  extensive  experimental  and  clinical 
investigation  as  has  chloroform. 

It  is  generally  conceded  that,  in  fatal  ether  toxemia,  respiration  fails 
before  circulation,  Eespiratory  failure  may  result  from  paralysis  of  the 
respiratory  center,  or  as  the  result  of  an  overdose,  or  it  may  occur  quite 
independently  of  this,  from  obstruction  of  the  air  passages  from  any 
cause.  Fatal  reflex  respiratory  shock  may  supervene  as  the  result  of  the 
surgical  procedure,  and  is  more  apt  to  occur,  in  consequence  of  reflex 
muscular  spasm,  during  the  lighter  stages  of  anesthesia  than  during  full 
surgical  narcosis. 

According  to  Hewitt,^  "The  all-important  point  concerning  respira- 
tory failure  in  moderately  healthy  patients  under  ether  is  that,  however 
such  failure  may  arise,  the  circulation  at  the  moment  when  breathing 
ceases  is  sufficiently  satisfactory  for  remedial  measures  to  he  almost 
invariably  successful.  The  heart  is  not  likely  to  fail  unless  restorative 
measures  be  too  long  delayed." 

According  to  Henderson,^  primary  cardiac  death  may  occur  under 
ether.  Primary  cardiac  failure  can  be  induced,  easily  and  with  cer- 
tainty, simply  with  ether.  Failure  to  recognize  this  in  the  past  has  been 
due,  he  asserts,  mainly  to  the  fact  that  dogs  have  hitherto  been  the 
principal  experimental  animals,  and  dogs  rarely  exhibit  the  phenomena. 
Cats,  on  the  other  hand,  and  many  human  subjects,  after  being  rendered 

^  Fabre  and  Verrier :  < '  Influence  sur  la  lactation  de  1  'anesthesia  par  1  'ether, ' ' 
Bull,  de  la  Soc.  d.  Obstet.  et  de  Gynecol.,  May,  1912,  552, 

="  Hewitt:     "  Anffisthetics,  "  367   (1912). 

*  Henderson,  Yandell:  "Primary  Heart  Failure  in  Normal  Subjects  under 
Ether,"  Surg.,  Gynecol.,  and  Obstet.,  Aug.,  1911,  161. 


ETHER  193 

acapnic,  are  liable  to  die  of  primary  cardiac  failure  under  ether.  They 
are  hypersusceptible  to  ether  in  the  same  manner  that  acapnic  dogs  and 
acapnic  persons  are  hypersuscepti})le  to  chloroform.  Henderson  believes 
that  these  forms  of  death,  and,  in  fact,  by  far  the  greater  number  of 
all  deaths  under  anesthesia,  are  fundamentally  due  to  acapnia  resulting 
from  the  excessive  pulmonary  ventilation  of  the  stage  of  excitement. 

Stag'es  of  Ether  Anesthesia. — When  ether  is  administered  according 
to  the  most  modern  technique  (see  Administration,  p.  199),  the  sub- 
ject, as  a  rule,  quietly  passes  into  the  stage  of  surgical  anesthesia,  as  if 
falling  into  a  profound  sleep,  from  which  the  recovery  is  so  uneventful 
that  it  may  be  likened  to  the  awakening  from  normal  slumber. 

It  is  always  to  be  borne  in  mind,  however,  that  there  may  be  indi- 
vidual variations  from  the  usual  course  of  events,  even  with  the  most 
careful  technique.  When  the  anesthetist,  for  any  reason,  fails  to  employ 
the  various  auxiliary  measures  now  in  use,  the  stages  of  anesthesia  are 
quite  well  marked.     Four  stages  may  be  observed,  which  are  as  follows : 

First  Stage,  or  Stage  of  Light  Anesthesia. — In  the  last  edition  of  his 
"Anaesthetics"  (1912,  pp.  362-363)  Hewitt  states  that,  in  consequence  of 
the  pungent  and  rather  disagreeable  odor  of  ether,  "it  is  impossible  to 
avoid  completely  all  unpleasant  sensations  at  the  commencement  of  the 
inhalation."  This  is  so  easily  and  so  completely  accomplished  by  the 
preliminary  administration  of  an  alcoholic  solution  of  oil  of  bitter 
orange  peel  (see  p.  91),  that  it  seems  almost  unnecessary  to  give  in 
detail  the  phenomena  otherwise  noted  during  the  first  stage. 

This  stage  usually  occupies  the  first  two  minutes  of  the  inhalation. 
Eespiration  is  accelerated.  Blood  pressure  is  slightly  increased,  the 
pulse  is  full  and  bounding,  and  the  color  refiex  is  heightened.  If  the 
vapor  is  administered  in  too  great  concentration,  there  may  be  holding 
of  the  breath,  swallowing,  closure  of  the  glottis,  a  feeling  of  suffocation, 
muscular  rigidity,  coughing,  and  turning  of  the  head  from  side  to  side. 
The  pupils  are  dilated.  The  special  senses  are  disturbed,  though  the 
order  in  which  they  are  affected  has  not  been  definitely  determined. 

Second  Stage,  or  Stage  of  Excitement. — With  ether,  as  with  chloro- 
form, this  stage,  so  far  as  the  excitement  is  concerned,  should  not  occur. 
It  is  obviated  in  part  or  in  full  by  the  utilization  of  modern  technique, 
which  calls  for  the  adaptation  of  the  method  to  the  individual  case.  In 
any  event,  this  stage  is  marked  by  the  more  or  less  abrupt  loss  of  con- 
sciousness, with  the  consequent  interference  with  memory,  volition,  and 
intelligence.  The  subject,  however,  responds  to  stimuli,  and  may  give 
evidence  of  apparent  consciousness.  Words  and  sentences  become  more 
and  more  incoherent,  and  crying,  singing,  or  laughing,  shouting,  and 
struggling  may  initiate  a  typical  stage  of  excitement.  As  the  anesthesia 
deepens,  marked  rigidity  of  the  muscles,  clonic  or  tonic  contractions, 
partially  of  certain  muscles,  notably  the  muscles  of  the  jaw  and  larynx, 


194  ANESTHESIA 

appear.  The  pupils  continue  to  be  dilated  and  mobile.  Mucus  and 
saliva  are  now  freely  secreted.  The  face  is  flushed,  and,  unless  care  is 
exercised  in  keeping  the  airway  clear,  cyanosis  may  occur.  Perspiration 
now  appears  over  the  face  and  other  parts  of  the  body.  The  pulse  is  still 
accelerated,  full  and  bounding.  Eespiration  may  now  become  irregular, 
and  apnea  may  occur,  the  cessation  of  .breathing  lasting  for  variable 
lengths  of  time.  The  "ether-tremor,"  to  which  reference  has  been  made, 
sometimes  occurs  during  this  stage,  the  patient  shaking  with  quite 
noticeable  violence.  This  is  more  apt  to  occur  as  the  subject  is  emerging 
from  than  when  going  under  the  influence  of  the  anesthetic.  In  either 
event  this  phenomenon  disappears  with  the  deepening  of  the  anesthesia. 
Vomiting  occurs,  if  at  all,  during  the  transition  from  the  second  to  the 
third  stage.  The  muscles  particularly  concerned  in  respiration  are  now 
no  longer  subject  to  reflex  stimulation,  and,  as  the  subject  passes  into 
the  third  stage,  they  become  so  flaccid  that  there  is  no  longer  danger  of 
serious  interference  with  respiration  from  this  cause. 

Third  Stage,  or  Stage  of  Surgical  Anesthesia. — The  recognition  of 
this  stage  of  anesthesia  is  important,  inasmuch  as  the  subject  is  not  in 
condition  for  operative  interference  until  this  time.  The  indications  of 
normal  surgical  anesthesia  may  be  briefly  stated  as  follows : 

(1)  Respirations  regular,  deep,  and  softly  stertorous. 

(2)  Muscles  of  extremities  lax. 

(3)  Color  of  face,  ears,  and  lips  about  normal. 

(4)  Pupils  reactive  to  light. 

(5)  Lid  reflex  weakly  present. 

(6)  Coughing  reflex  absent. 

(7)  Phonation  absent. 

It  is  to  be  borne  in  mind  that  there  may  be  greater  or  less  variation 
from  the  indications  of  what  may  be  called  normal  surgical  anesthesia, 
but  this  is  not  sufficient  to  obscure  the  recognition  of  this  stage. 

The  respirations  are  now  regular,  full,  and  generally  audible.  A 
soft  stertor  may  be  considered  normal,  but  if  breathing  becomes  strongly 
stertorous  it  is  an  indication  of  some  obstruction  in  the  airway.  The 
respirations  are  the  principal  guide  as  to  the  depth  of  narcosis.  When 
the  regular,  automatic,  respiratory  action  is  obtained,  this  should  be 
maintained,  bearing  in  mind  slight  variation  in  different  individuals. 
A  decrease  in  the  depth  and  amplitude  of  respiration  indicates  a  return 
to  consciousness,  and  calls  for  an  increased  amount  of  the  anesthetic. 
An  increase  in  stertor  should  be  modified  by  changing  the  position  of 
the  lower  jaw  or  head. 

Cyanosis  is  not  present  in  normal  anesthesia. 

The  heart  action  is  accelerated,  compared  with  the  normal,  during 
this  stage,  and  the  pulse  is  full,  bounding,  and  regular,  usually  varying 
from  80  to  110  per  minute.     As  the  anesthesia  progresses  the  face  may 


ETHER  195 

become  more  flushed  than  normal.  Blood  pressure,  as  a  rule,  remains 
constant. 

The  pupils,  when  no  preliminary  medication  is  used,  may  be  slightly 
dilated  (from  3iA  to  4i/^  mm.),^  or  they  may  contract  to  normal,  re- 
maining so  throughout  this  stage.  The  eyeballs  are  generally  fixed, 
though  they  may  be  rolling. 

Eelaxation  of  all  the  muscles  now  occurs,  the  continuance  of  this 
stage  depending  upon  the  further  conduct  of  the  administration.  (See 
Administration,  p.  199.) 


_l_^''   *    *^.       6       6V.     T    X    ^  ^ 

?rtTT\TTTTlTTTT/T7Tr^    if^   i   .   .^l   .   ■   J,   ^   ,„,   ,   I         '" 


\y  'vl  1 1  ( 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1  III  1 1 1  iTtmr 


Fig.  61.— The  Pupillometer. 


lllMllli 


The  third  stage  of  anesthesia  may  change  in  the  direction  of  (1) 
return  to  consciousness,  or  (2)  deepening  narcosis,  or  the. beginning  of 
the  fourth  stage. 

The  indications  of  returning  consciousness  may  be  summarized  as 
follows : 

(1)  Eespiration  weak. 

(2)  Pallor  of  face. 

(3)  Swallowing  movements. 

(4)  Pupils  dilated. 

(5)  Lid  reflex  return. 

(6)  Lachrymation  excessive. 

(7)  Phonation  returns. 

These  phenomena  call  for  an  increased  amount  of  the  anesthetic. 

Fourth  Stage,  Stage  of  Deepening  Narcosis,  or  Stage  of  Overdose. — 

The  indications  of  the  onset  of  this  stage  may  be  summarized  as  follows : 

(1)  Respirations  weak. 

(2)  Dusky  appearance  of  face  (cyanosis). 

(3)  Pulse  soft,  feeble,  irregular. 

(4)  Pupils  dilated;    no  reaction  to  light. 

(5)  Eyeballs  fixed  and  dry. 

(6)  Eyelids  separated. 

The  first  indications  of  impending  overdose,  ordinarily  noted  by  the 
administrator,  are  the  irregular  pulse  and  the  quiet  feeble  respirations. 
The  muscles  become   flaccid.     Blood  pressure   is   markedly  decreased. 

^  It  may  be   noted   here  that   the   average   ether   pupil,    as  measured   by    the 
pupillometer,  is  larger  than  the  average  chloroform  pupil  (see  p.  308). 


196  ANESTHESIA 

When  etlier  is  given  in  an  overwhelming  dose,  the  heart  may  be  paralyzed 
immediately  after  paralysis  of  respiration. 

Elimination. — Nicloux  ^  investigated  the  elimination  of  ether,  after 
the  narcosis,  and  found  that  the  quantity  of  ether  amounts  to  about  150 
mg.  per  100  c.c.  of  blood,  immediately  after  the  cessation  of  the  inhala- 
tion; then  the  amount  of  ether  in  the  blood  rapidly  diminishes,  so  that 
only  one-half  of  the  above  quantity  is  demonstrable  at  the  end  of  five 
minutes.  Only  traces  of  ether  can  be  detected  after  two  hours,  and  none 
is  left  after  four  hours. 

As  compared  to  the  elimination  of  chloroform,  the  elimination  of 
ether  must  be  designated  as  very  rapid. 

These  findings  are  in  keeping  with  the  observations  of  other  investi- 
gators. 

After-Ejffects. — The  after-effects  of  ether  narcosis  may  be  considered 
under  two  heads,  viz. :     (1)  Immediate,  and  (2)  Eemote. 

Immediate  After-Effects. — It  has  been  stated  that  if  ether  is  admin- 
istered according  to  modern  methods,  with  the  utilization  of  preliminary 
and  accompanying  factors,  the  subject  emerges,  as  a  rule,  from  the  anes- 
thetic state  as  if  from  normal  sleep,  feeling  no  ill  effects  so  far  as  the 
anesthesia  is  concerned.  Under  other  circumstances,  however,  even  with 
the  most  careful  technique,  the  recovery  period  may  be  marked  by  retch- 
ing, nausea,  and  vomiting.  Hematemesis  sometimes  occurs,  and  very 
rarely  hemoptysis  is  encountered.^  Transient  mental  disturbances, 
amounting  in  some  instances  to  mania  and  dementia,  have  been  reported. 
Muscular  excitement  may  be  noted  for  a  brief  period,  and  in  rare  in- 
stances choreiform  movements  have  been  known  to  last  for  two  or  three 
weeks.  Cerebral  hemorrhage,  with  resulting  hemoplegia,  has  been  noted 
in  persons  with  arteriosclerosis.  Pulmonary  complications  ("ether- 
bronchitis'^  and  "ether-pneumonia")  are  among  the  most  frequent  early 
after-effects. 

Remote  After-Effects. — The  remote  after-effects  of  ether  narcosis  are 
not  of  such  frequent  occurrence  and  severity  as  follow  the  use  of  chloro- 
form. Many  interesting  observations  have  been  made,  however,  particu- 
larly with  reference  to  the  results  of  the  action  of  ether  upon  the  various 
organs. 

The  studies  of  Boss  and  Hawk  ^  consisted  primarily  of  an  inquiry 
into  the  influence  of  diet  and  of  a  subnormal  body  temperature  upon 
post-anesthetic  glycosuria.     The  subjects  used  were  dogs,  and  the  anes- 

^  Loc.  cit. 

^Hewitt:     Loc.  cit.,  375. 

'Ross  and  Hawk:  "Further  Studies  on  the  Metabolic  Influence  of  Ether 
Anaesthesia,"  from  the  Laboratory  of  Physiological  Chemistry  of  the  University 
of  Illinois,  Dec,  1911. 


ETHER  197 

thesia  was  brought  about  either  by  means  of  specially  prepared,  so-called 
"dehydrated,"  ether,'^  or  by  ether  U.  S.  P.  Two  methods  of  administra- 
tion were  employed:  one  a  compressed  air  method  in  which  the  appara- 
tus concerned  was  similar  to  that  of  Gwathmey;  whereas,  in  the  other 
instance,  the  ordinary  co7ie  method  was  utilized.  In  a  portion  of  the 
experiments  a  specially  devised  apparatus  was  employed  to  maintain  the 
normal  temperature  of  the  animal  during  the  anesthesia  period.  In  each 
instance  this  period  was  two  hours  in  duration. 

When  fed  diets,  principally  meat,  containing  from  3.3-4.1  grams  of 
carbohydrate  per  kilogram  body  weight,  the  dogs  gave  no  evidence  of 
post-anesthetic  glycosuria  under  any  conditions,  i.  e.,  with  either  type 
of  anesthetic,  either  method  of  administration,  or  after  a  pronounced 
lowering  of  the  body  temperature.  When  the  carbohydrate  portion  of 
the  diet  was  entirely  replaced  by  meat,  post-anesthetic  glycosuria  was 
observed  in  every  instance,  irresjDective  of  the  character  of  the  anesthetic, 
the  mode  of  its  administration,  or  the  course  of  the  body  temperature. 
All  urines  were  examined  qualitatively  by  means  of  copper  and  bismuth 
reduction  tests,  and  quantitatively  by  means  of  fermentation  and  polar- 
ization. 

Grube  ^  investigated  the  influence  of  ether  narcosis  upon  the  body 
temperature  and  the  carbohydrate  metabolism.  According  to  his  obser- 
vations, the  glycosuria  which  follows  upon  the  ether  narcosis  in  dogs, 
often  also  in  man,  can  be  prevented  by  counteracting  the  simultaneous 
lowering  of  the  body  temperature,  which  is  produced  by  the  vasodilator 
effect  of  the  ether,  combined  with  the  arrest  of  muscular  activity. 

The  conclusions  of  Hawk,^  after  careful  animal  experimentation  with 
reference  to  the  effects  of  ether  upon  the  urine,  are  as  follows: 

(1)  An  initial  diuresis  proportional  to  the  length  of  anesthesia  fol- 
lows ether  narcosis,  varying  from  thirty  minutes  to  four  and  one-half 
hours. 

(2)  Ether  anesthesia  invariably  caused  the  animal  to  lose  weight 
upon  the  day  of  the  narcosis. 

(3)  The  fractions  of  urine  first  voided  after  ether  anesthesia  pos- 
sessed specific  gravities  ranging  from  1.024  to  1.042,  as  compared  with 
the  normal  specific  gravity  of  1.015  to  1.019. 

^  This  ether  was  later  found  by  Baskerville  to  contain  even  more  acetaldehyd 
than  the  ether  U.  S.  P.  used.  Consequently,  it  may  be  concluded  that  the  usual 
or  even  excessive  amounts  of  acetaldehyd  present  in  anesthetic  ether  play  little 
or  no  part  in  the  production  of  post-anesthetic  glycosuria. 

^  Grube :  ' '  Ueber  den  Einfluss  der  Aethernarkose  auf  die  Korpertemperatur 
und  den  Kohlehydratestoffwechsel, "  Pflilger's  Arch.  f.  d.  ges.  Physiol.,  1911, 
138,  601. 

^  Hawk,  P.  B. :  "On  the  Diuresis  Following  Ether  Narcosis, ' '  J.  Med.  Ees., 
1908-1913,  203. 


198  ANESTHESIA 

Seelig  ^  summarizes  the  result  of  his  investigations  concerning  ether 
as  follows : 

(1)  Ether  inhalation  always  produces  a  more  or  less  marked  glyco- 
suria in' dogs  which  are  fed  on  meat. 

(2)  The  glycosuria  is  always  demonstrahle  during  the  narcosis,  but 
lasts  only  a  short  time  beyond  it. 

(3)  Persistent  carbohydrate-feeding  prevents  the  occurrence  of 
glycosuria  in  dogs. 

(4)  Suppression  of  an  existing  ether  glycosuria,  through  subsequent 
intravenous  oxygen  infusion,  is  not  feasible. 

(5)  The  glycosuria  is  associated  with  hyperglycemia. 

(6)  The  glycogen  contents  of  the  liver  are  greatly  diminished  after 
ether  narcosis. 

(7)  No  glycosuria  occurs  when  the  ether  inhalation  is  combined  with 
a  simultaneous  intravenous  infusion  of  oxA'gen,  provided  that  correct 
dosage  of  oxygen  is  administered. 

(8)  Intravenous  introduction  of  CO,  does  not  give  rise  to  glycosuria. 
Eohricht  ^  examined  the  urine  of  100  patients  who  had  been  operated 

upon  under  ether  narcosis,  as  to  the  appearance  of  glycosuria,  with 
positive  findings  in  twelve  cases.  He  arrived  at  the  conclusion  that 
neither  the  operative  traumatism  nor  the  quantity  of  the  ether  admin- 
istered and  the  duration  of  the  narcosis  stand  in  a  direct  causative  rela- 
tion to  the  resultant  glycosuria;  but  that  this  must  be  interpreted  as  a 
consequence  of  an  injury  to  the  organism  through  the  inhaled  ether. 
The  exact  nature  of  this  injury  is  problematical,  Eohricht  finding  no 
sufficient  explanation  in  the  fat-infiltration  of  the  liver,  or  in  the  chem- 
ical and  mechanical  action  of  ether  on  the  blood,  or  in  an  influence  upon 
the  nervous  organs.  In  his  opinion,  several  partly  unknown  effects  of 
the  ether  must  coincide  in  order  to  produce  the  glycosuria.  A  glyco- 
suria-producing  property  of  the  ether  can  hardly  be  imagined  in  the 
absence  of  an  individual  predisposition.  In  his  opinion,  advanced  age 
has  a  certain  bearing  upon  the  occurrence  of  post-narcotic  glycosuria. 
Undoubtedly,  however,  the  ether  narcosis  may  be  the  cause  of  an  abnor- 
mal composition  of  the  urine. 

In  a  study  of  acetonuria  following  ether  anesthesia  Hamblen  ^  found, 
in  120  cases  etherized  by  the  cone  method,  acetonuria  developed  in  88.5 
per  cent.  In  the  same  number  anesthetized  by  the  drop  method  only  26 
per  cent  showed  acetonuria.     (For  further  discussion  of  this  subject,  see 

*  Seelig :  ' '  Ueber  Aetherglykosurie  und  ihre  Beeinflussung  durch  intravenose 
Sauerstoflanfusionen, "  Arch.  exp.  Pathol,  1905,  52,  481. 

^  Eohricht,  E. :  "  Klinische  Beobaehtungen  iiber  Glykosurie  iiach  Aethernar- 
kosen,"  Beitr.  zur  Uin.  Chir.,  1906,  48,  535. 

'  Hamblen :  ' '  The  Occurrence  of  Acetonuria  Following  Ether  Anesthesia, ' ' 
Univ.  Penn.,  Med.  Bull.,  June,  1909. 


ETHER  199 

Chapter  IX,  Treatment  Before,  During,  and  After  Anesthesia,  p.  365, 
section  on  "Post-Anesthetic  Toxemia.") 

Engelhardt  ^  affirms  a  specific  toxic  action  of  the  narcotic  agent,  more 
particularly  ether,  and  the  affections  of  the  lungs  are  referred  hy  him  to 
cytolytic  or  hemolytic  processes  (aside  from  pulmonary  edema  through 
overdosage,  and  coarse  aspiration-pneumonia) .  The  onset  of  pulmonary 
changes,  after  ether  narcosis,  depends,  in  his  opinion,  upon  the  "melting 
point"  of  the  red  blood  corpuscles  and  the  quantity  of  ether  absorbed  by 
the  erythrocytes  and  the  blood-plasm  on  the  one  hand,  and  upon  the 
temperature  of  the  body  on  the  other  hand.  As  the  small  quantity  of 
anesthetic  which  has  passed  into  the  blood  can  rarely  be  ascertained,  he 
emphasizes  that  this  cell-dissolving  action  represents  the  highest  de- 
gree— the  only  one  that  can  be  tested  experimentally,  however — of  the 
injurious  influence  of  the  narcotic  agent  upon  the  body  cells.  In  support 
of  his  argument,  he  mentions  the  fact  that  a  decrease  in  the  number  of 
post-operative  pneumonias  is  noted  in  narcosis  with  morphin-scopola- 
min  as  well  as  in  spinal  anesthesia. 

In  discussing  post-operative  pulmonary  complications  and  throm- 
boses after  ether  narcosis,  Otte  ^  says  that  excellent  results  were  obtained 
in  regard  to  pneumonia,  bronchitis,  secretion  of  mucus,  and  thrombosis. 
The  narcotic  was  repeatedly  administered  in  the  presence  of  pulmonary 
complications,  such  as  tuberculosis,  asthma,  or  bronchitis,  without  any 
essential  aggravation  of  the  bronchitis,  or  rise  of  temperature.  As  a 
very  important  and  useful  aid  in  ether  narcosis,  as  well  as  in  all  other 
inhalation  narcoses,  he  recommends  systematic  inhalations  of  warm 
ivater-vapor,  before  and  after  the  narcosis,  preferably  ivith  an  admixture 
of  thymol  and  salicylic  acid. 


ADMINISTRATION   OF   ETHER 

The  Open  or  Drop  Method. — The  administration  of  ether  alone  by 
the  drop  method,  and  continuously  on  an  open  mask,  is  not  as  desirable 
as  certain  other  methods.  Many  surgeons  and  anesthetists,  however, 
prefer  this  method  to  any  other,  and  for  this  reason  the  best  procedure 
of  administration  will  be  fully  described,  but  not  until  the  necessary  pre- 
liminaries have  been  considered. 

The  Dropper. — It  is  better  to  drop  the  ether  from  the  original  con- 
tainer than  to  pour  the  contents  into  some  patented  or  other  dropper. 
No  container  holding  over  100  grams,  or,  at  the  most,  a  quarter  of  a 

^Engelhardt:  "Ziir  Entstehungsursache  postoperativer  Pneumonien, "  Centr. 
Chir.,  1907,  No.  4,  89. 

^  Otte,  A. :  "  Ueber  die  postoperativen  Lungenkomplikationen  und  Throm- 
bosen  nach  Aethernarkosen, "  Miinch.  med.  Woch.,  1907,  No.  50,  2473. 


200 


ANESTHESIA 


pound,  should  be  used.    Internes  and  others  using  original  tin  contain- 
ers as  droppers  often  neglect  to  cut  out  the  top  and  replace  the  same 


Fig.  62. — Dropper  From  Original  Can,  Old  Form. 


with  a  cork  after  perforating  this  top  to  admit  of  its  use  as  a  dropper. 
In  this  way  quite  as  much  ether  may  be  wasted  as  is  used.  It  is  more 
important  to  maintain  the  original  purity  of  the  ether  used.  Four  good 
methods  for  making  a  dropper  out  of  an  original  tin  container  are  as 
follows : 

First:    Bend  a  safety  pin  as  shown  in  the  illustration,  then  pass  it 
through  the  cap  on  the  neck  of  the  ether  can,  when  the  free  end  may 

be  again  straight- 
ened. Then  clasp 
safety  pin  and  drop 
from  either  end. 

Second:  A  num- 
ber of  pin  holes  are 
made  in  the  top  of 
the  neck  of  the  can. 
A  small  piece  of  sur- 
gical gauze  is  now 
placed  over  these 
holes  and  twisted  so 
as  to  come  to  a 
point.  This  gauze 
prevents  the  ether 
from  squirting  out 
of  the  can.  When 
the  can  is  not  in  use  a  small  piece  of  surgeon's  plaster  may  be  placed  over 
the  pinholes  to  prevent  excessive  evaporation ;  or,  preferably,  the  top  may 
be  cut  out  and  a  clean  velvet  cork  inserted.    It  is  inadvisable  to  use  the 


Fig.  63a. — Chloroform  and  Ether  Containers 
FOR  THE  Drop  Method. 


ETHER 


201 


remainder  of  this  ether,  even  with  these  precautions,  if  it  has  to  be  kept 
for  any  length  of  time,  say,  for  a  week  or  more.  (See  page  HUH.) 
However,  there  are  occasions  when  only  small  amounts  of  ether  are  used 


Fig.  63b. — Chloroform  and  Ether  Containers  for  the  Drop  Method. 


in  an  operation,  and  many  short  operations  may  quickly  follow  each  other. 
In  such  event  the  container  may  be  used  until  the  ether  is  consumed. 

Third:    When  a  new  can  is  to  be  used,  or  the  cans  above  described 
are  to  be  used  again,  a  safety  pin,  one  inch  long  or  more,  bent  in  the 
middle  at  right  angles,  is  placed  by  the  side 
of  the  cork,  and  pin  and  cork  are  inserted     * 
into   the  can.      (Fig.   63b.)      The   rate  of 
flow  of  ether  may  be  regulated  perfectly  by 
pressing  the  thumb  against  the  protruding 
part  of  the  bent  pin.     The  cork  should  be 
firmly  inserted  to  avoid  its  being  pushed 
out  by  this  pressure.     The  cork  may  often- 
times be  used  again.     This,  of  course,  de- 
pends upon  its  condition. 

Fourth:  Notch  the  cork  very  slightly, 
place  a  small  piece  of  gauze  in  the  notch 
and  insert  in  the  neck  of  the  can,  after 
cutting  out  the  top.  Mechanical  obstruc- 
tions, such  as  pieces  of  cork,  may,  how-  Fig. 
ever,  interfere  with  the  flow  of  ether.  The 
cork  should  not  be  used  again. 

An  excellent  tin  container,  so  arranged  for  dropping  ether,  has  re- 
cently appeared  upon  the  market.  The  illustration  (Fig.  64)  is  seK- 
explanatory. 


64. — Ether      Container 
WITH  Dropper. 


202 


ANESTHESIA 


Ether  is  also  now  obtainable  in  glass  ampules,  so  constructed  that, 
by  snipping  the  tip  thereof,  they  may  be  used  as  droppers;   or  the  neck 


Fig.  65. — Glass  Container  for  Holding  Ether. 

may  be  cut  off  and  the  contents  poured  into  a  vaporizer.  The  ampules 
are  made  by  one  company  of  actinic  and  by  another  of  anactinic  glass; 
the  latter  protects  the  ether  from  decomposition  by  light    (Fig.   65). 


Fig.  66. — Lumbard's  Rubber.  Ether  Blanket  and  Elastic  Mask  Holder. 


The  Mask. — The  usual  mask  consists  of  a  wire  frame  and  metal  hoop 
for  holding  the  gauze  in  place.  When  an  ordinary  ether  mask  is 
used  without  towels,  gauze,  or  something  else  around  the  mask,  much 
of  the  vapor  is  blown  into  the  air  by  the  patient's  breath,  the 
surgeons,  anesthetist,  and  nurses  getting  the  full  benefit  of  it,  and,  in 
a  private  house,  the  disagreeable,  penetrating  odor  will  linger  almost  as 


ETHER 


203 


Fig.  67. — Yankauer-Gwathmey  Drop  and  Vapor  Mask. 


long  as  if  the  cone  had  been  used.  The  patient  gets  the  cold  vapor  that 
sinks  through  the  mask.  Everyone  suffers  in  consequence  of  this  crude 
and  antiquated  method. 

The  prevention  of  waste  and  the  administration  of  the  ether  in  the 
most  acceptable  way  by  this  method  are  accomplished  as  follows : 

The  mask  is  covered  with  as  many  thicknesses  of  gauze  as  possible 
without  interference  with  free  respiration  (from  1/16  to  %  of  an  inch  in 
thickness).  '  The  patient  thus  receives  a  more  perfect  vapor  than  if  only 
one  or  two  layers  of 
gauze    are    used, 
consequently    there 
is  much  less  irrita- 
tion to  the  respira- 
tory passages. 

The  Yankauer 
Mask. — The  Yan- 
kauer mask,  of 
closely  woven  wire 
over  which  are 
stretched        several 

layers  of  gauze,  is  one  of  the  best  masks  for  the  drop  method  of  ether  or 
chloroform. 

The  FERGUSOiSr  Mask. — The  best  mask  yet  devised  for  the  drop 
method  for  ether  alone  is  that  devised  by  Ferguson.  It  consists  of  a 
wire  frame,  so  flexible  that  it  can  easily  be  adjusted  to  the  face  by  bend- 
ing the  wire  between  the  fingers.  It  is  covered  with  several  thicknesses 
of  gauze,  which  are  held  in  place  by  a  wire  band.  The  unusual  feature 
consists  of  a  wire  frame  surrounding  this  gauze  mask,  over  which  is 
stretched  a  canton  flannel  bag,  with  a  small  hole  either  in  the  middle  or 
on  the  side,  depending  upon  whether  the  patient  is  in  the  dorsal  or 
lateral  position.  This  outer  covering  of  canton  flannel  prevents  the 
blowing  of  the  ether  vapor  all  over  the  room.  The  best  feature  of  this 
mask  is  that  it  gives  the  patient  a  warmer  vapor.  It  is  really  semi- 
closed,  a  certain  amount  of  rebreathing  taking  place,  but  not  as  much  as 
is  usual  with  a  rubber  bag.  As  the  mask  is  not  air-tight,  it  is  in  a 
measure  automatic,  and  does  not  require  so  intimate  a  knowledge  of  the 
physiological  action  of  ether  to  maintain  the  surgical  level  called  for  by 
the  operation.  The  patient  is  not  subjected  to  cold  ether  vapor,  as  with 
the  cone  or  ordinary  mask,  and  consequently  comes  out  of  the  anesthetic 
in  a  better  condition. 

The  Mayo  brothers,  of  Eochester,  Minn.,  have  probably  used  the  drop 
method  of  ether  for  a  longer  period  of  time  and  had  a  larger  number  of 
administrations  than  any  other  surgeons.  They  report  between  14,000 
and  20,000  administrations.    The  following  is  their  method: 


204 


ANESTHESIA 


"All  patients  are  anes- 
thetized on  the  operating  table 
in  the  operating  room,  while 
preparation  of  the  patient  is 
going  on  at  the  same  time. 
This  is  one  of  the  important 
factors  in  producing  a  rapid 
surgical  narcosis. 

"An  acute  cold  is  a  contra- 
indication to  any  anesthetic, 
but  as  soon  as  the  cold  be- 
comes chronic  there  is  not 
much  danger  from  etheriza- 
tion, and,  instead  of  operating 
during  an  acute  cold  and  giv- 
ing chloroform  (unless  in  an 
emergency),  we  wait  a  few 
days  until  the  acute  attack  has 
passed,  and  then  they  are  as 
good  subjects  for  ether  as  for 
any  other  anesthetic.  Chronic 
bronchitis  is  often  improved 
by  an  anesthetic. 

"Use  a  four-ounce  ether 
can  and  fit  an  ordinary  cork 
with  a  groove  on  either  side 
into  its  mouth,  fill  one  groove 
with  absorbent  cotton  and  let 
it  extend  out  of  the  can  about 
one  inch.  One  can  regulate 
the  drop  easily  by  the  manner 
in  which  the  point  is  clip]3ed. 
We  usually  fix  two  cans,  one 
with  a  large  dropper,  and  use 
it  until  the  patient  is  fully 
under  the  anesthetic,  and  then 
change  to  the  other  can  with 
the  small  dropper,  and  con- 
tinue its  use  during  the  opera- 
tion. The  inhaler  used  is  the 
improved  Esmarch,  with  two  thicknesses  of  stockinet  (frame  boiled  and 
stockinet  changed  after  each  patient).  We  drop  as  slowly  and  carefully 
in  giving  the  ether  as  though  it  were  chloroform,  until  the  patient's  face 
is  flushed,  and  then  a  few  layers  of  surgeon's  gauze  are  added,  and  the 


Fig.  68.— The  Ferguson  Mask.  A,  B,  C,  E, 
wire  frame;  E,  retaining  wire;  D,  gauze; 
F,  canton  flannel  hood;  G,  opening  in  hood 
for  air;  also  used  to  drop  anesthetic  on  to  D; 
K,  open  chamber;  M,  under  surface  of  the 
mask  next  to  patient's  face. 


ETHER  205 

ether  is  given  a  trifle  faster  until  the  patient  is  surgically  etherized  ;  then 
return  is  made  to  the  same  covering  as  at  the  start,  and  the  regular  drop 
continued  throughout  the  operation.  A  patient  can  be  brouglit  under 
ether  in  this  way  in  from  three  to  five  minutes,  and,  when  ready,  patients 
do  better  if  the  operation  is  started  at  once. 

"As  it  requires  very  little  ether  to  keep  a  patient  surgically  cthcri/ed, 
one  can  change  to  the  small  dropper  during  the  operation.  A  much 
deeper  narcosis  is  required  to  start  an  operation  or  to  make  the  incision 
than  later  on  when  the  operation  is  in  progress.  Patients  should  be 
prepared  for  each  stage  of  the  anesthesia  with  an  explanation  of  just 
how  the  anesthetic  is  expected  to  affect  him;  'talk  him  to  sleep,'  with 
the  addition  of  as  little  ether  as  possible.  We  have  one  rule :  patients 
are  not  allowed  to  talk,  as  by  talking  or  counting  patients  are  more  apt 
to  become  noisy  and  boisterovis.  ISTever  bid  a  patient  to  'breathe  deep,' 
for  in  so  doing  a  feeling  of  suffocation  is  sure  to  follow,  and  the  patient 
is  also  apt  to  struggle."  ^ 

Davis  gives  the  following  as  his  method  of  administration  of  ether 
by  the  drop  method :  ^ 

"Place  a  piece  of  rubber  protector  over  the  patient's  eyes  to  shield 
them  from  the  ether  vapor.  Protect  the  face  with  a  moist  towel  or  gauze 
which  extends  over  the  rubber  tissue  and  around  the  chin.  Use  a  wire 
frame  mask  similar  to  the  Esmarch  chloroform  inhaler,  only  larger,  in 
order  to  give  more  space  under  the  inhaler  for  the  mixture  of  air  and 
ether.  Cover  the  wire  frame  with  one  or  two  layers  of  stockinet  or 
several  layers  of  gauze.  The  gauze  should  be  thrown  away  and  the  wire 
frame  boiled  after  each  administration. 

"Apply  the  mask  to  the  patient's  face  and  administer  the  ether  drop 
by  drop,  very  slowly  at  first,  then  gradually  increasing  as  the  patient  is 
able  to  take  the  stronger  vapor.  When  the  patient  cannot  respond  to 
questions,  a  moist  towel  or  gauze  is  wrapped  snugly  around  the  mask, 
leaving  a  small  area  in  the  center  for  the  free  passage  of  air  through  the 
gauze.  By  this  method  the  air  is  prevented  from  escaping  around  the 
edges  of  the  mask,  and  is  made  to  pass  through  the  ether-laden  gauze. 
The  ether  should  not  be  dropped  down  faster  than  the  patient  can  com- 
fortably breathe  it  in.  Never  be  in  a  hurry  to  put  the  patient  to  sleep. 
Do  not  let  an  impatient  operator  worry  or  hurry  you  on,  as  the  welfare 
of  the  patient  depends  upon  the  slow  and  gradual  ratio  of  the  increasing 
concentration  of  the  ether-vapor.  The  patient  will  become  unconscious 
in  two  or  three  minutes,  and  should  be  ready  for  the  operator  in  ten 
minutes.     After  the  patient  has  become   completely  anesthetized  very 

^ Magaw,  Alice :  "A  Eeview  of  ' Over  Fourteen  Thousand  Surgical  Anesthe- 
sias,' "  Surg.  Gyn.  mid  Ohst.,  Dec,  1906,  795-799. 

-  Davis,  S.  Griffith :  ' '  The  Administration  of  Ether  by  the  Drop  Method, ' ' 
Md.  Med.  J.,  May,  1907. 


206 


ANESTHESIA 


little  ether,  dropped  slowly,  but  continuously  will  suffice  to  maintain  the 
proper  condition.  Having  reached  surgical  anesthesia,  the  further  efforts 
of  the  anesthetist  should  be  devoted  to  observing  the  respiration,  pulse, 
pupils,  and  the  patient's  general  condition,  and  to  prevent  him  from 
passing  into  that  dread  stage  of  respiratory  paralysis.  The  respiration 
should  be  quiet,  with  perhaps  a  very  slight  snore.  Panting  and  rapid 
breathing,  or  irregular  stertorous  breathing,  indicate  that  the  patient 
needs  more  air." 

Ethyl   Chlorid  Ether   Sequence  by  the   Drop  Method. — Using  an 
ordinary  Esmarch  inhaler,  with  a  lozenge-shaped  aperture  cut  in  the 


Fig.  69. — Davis  Dropper  for  Insertion  in  Original  Container. 

rubber  tissue  which  is  placed  over  the  gauze  covering  the  mask,  encircle 
the  mask  with  a  towel  so  as  to  have  more  or  less  rebreathing.  Com- 
mence dropping  the  ethyl  chlorid  upon  the  mask  until  the  patient 
reaches  unconsciousness.  Now  begin  dropping  ether.  If  the  patient 
swallows,  or  shows  any  signs  of  returning  consciousness,  continue  drop- 
ping the  ethyl  chlorid  until  this  disappears,  then  recommence  with 
the  ether.  Continue  in  this  way  until  full  surgical  narcosis  is  reached, 
when  the  ethyl  chlorid  may  be  discontinued.  The  ether  may  now  be 
continued  by  the  drop  method,  as  already  outlined,  or  ethyl  chlorid 
may  be  sprayed  intermittently  for  five  to  ten  seconds  on  the  mask  until 
the  second  stage  is  reached,  when  a  switch  may  be  made  to  ether.  If 
signs  of  consciousness  ensue,  ethyl  chlorid  must  be  continued  to  be  inter- 
mittently sprayed,  the  ether  at  the  same  time  being  dropped  upon  the 
mask. 

The  Ethyl  Chlorid-Ether-Chloroform  Sequence. — The  change  to 
chloroform  should  not  be  made  until  the  patient  is  in  full  ether  anes- 
thesia. The  anesthetist  should  then  allow  the  reflexes  to  become  slightly 
active  and  the  chloroform  should  be  commenced  very  gradually.     The 


ETHER  207 

change  to  chloroform  should  be  made  if  there  is  profuse  secretion  of 
mucus  and  saliva  following  the  ethyl  chlorid  and  ether. 

The  Ethyl  Chlorid-Ether  Sequence  by  the  Closed  Method. — The 
ethyl  chlorid  anesthesia  may  be  induced,  as  fully  given  in  the  (chapter 
upon  Ethyl  Chlorid,  and  a  switch  can  then  be  made  to  ether  by 
revolving  the  ether  chamber.  It  is  safer  and  better  from  every  stand- 
point to  admit  the  ethyl  chlorid  from  the  bottom  of  the  bag  instead  of 
near  the  patient's  face.  Two  to  five  c.c.  of  ethyl  chlorid  are  usually  suffi- 
cient to  obtain  the  anesthesia  desired  before  turning  on  the  ether. 

The  advantages  of  the  ethyl  chlorid-ether  sequence  are,  principally, 
the  rapidity  of  induction  and  freedom  from  the  second,  or  struggling, 
stage  of  anesthesia.  This  sequence  is  usually  much  quicker  than  the 
nitrous  oxid-ether  sequence. 

Whenever  the  open  or  closed  method  of  ethyl  chlorid-ether  is  used, 
ether  can  be  either  dropped  or  turned  on  very  gradually  much  earlier 
than  in  the  nitrous  oxid-ether  sequence. 

Warning!  With  the  ethyl  chlorid-ether  sequence  it  is  unnecessary 
to  carry  the  patient  to  full  surgical  narcosis.  The  anesthesia  induced 
by  ethyl  chlorid  is  usually  quiet  and  without  either  cyanosis  or  stertor. 
There  is,  however,  a  possibility  of  danger  in  the  initial  stages  from  sink- 
ing the  patient  too  deep.  Whenever  the  lid  reflex  is  entirely  abolished  a 
change  should  be  made.  It  is  unnecessary  to  wait  for  the  cornea  to 
become  insensitive.  Ethyl  chlorid-ether  sequence  is  especially  indicated 
for  children,  and  for  nervous  individuals,  who  might  be  frightened  by 
a  mask  or  bag  being  placed  over  the  face. 

Chloroform-Ether  Sequence. — When  morphin  has  been  given  as  a 
preliminary,  and  the  induction  is  preceded  by  the  use  of  a  few  drops  of 
farina  cologne  or  an  alcoholic  solution  of  oil  of  bitter  orange  peel,  a 
remarkable  difference  in  all  the  reflexes  may  be  noted  as  the  patient  goes 
under  the  anesthetic.  The  induction  will,  under  these  circumstances, 
proceed  to  the  second  stage  with  chloroform.  When  this  stage  is  reached, 
give  one  drop  of  ether  every  thirty  seconds  for  one  or  two  minutes,  then 
alternate  the  drops  of  ether  with  the  chloroform,  and,  finally,  as  the 
third  stage  is  reached,  continue  with  ether  unless  the  reflexes  become 
active,  when  a  few  drops  (3-8)  of  chloroform  can  be  given  and  the  ether 
continued.  This  is  the  safest  way  to  induce  anesthesia  when  ether  is  the 
terminal  anesthetic,  for  the  simple  reason  that  the  struggling  stage  will 
not  occur  if  careful  attention  is  given  to  the  small  details.  Ether  thus 
replaces  chloroform  at  what  is  known  as  the  dangerous  stage  of  anes- 
thesia. During  the  last  few  minutes  of  the  anesthesia  chloroform  may 
again  replace  the  ether.  In  this  way  the  patient  comes  out  of  the  anes- 
thetic without  noticing  the  odor  of  ether. 

The  change  from  ether  to  chloroform  must  take  place  when  the 
reflexes  are  slightly  active,  and  in  the  following  manner :     Commence 


208  ANESTHESIA 

with  one  drop  of  cliloroform  every  ten  seconds  and  note  whether  tlie 
reflexes  are  deepened  or  not,  then  change  to  two  drops,  and  then  to  three 
drops  every  ten  seconds.  It  will  be  found  that  the  patient  can  be  kept 
lightly  under  in  this  way,  and  between  the  second  and  third  stages  with- 
out causing  any  nausea  or  vomiting,  provided  some  preliminary  medica- 
tion has  been  given. 

Anesthol. — Neef 's  ^  definition  of  anesthol  is  "chloroform  modified  to 
increase  its  safety  without  impairing  its  anesthetic  usefulness."  For  a 
full  discussion  of  anesthol  see  Chapter  XX. 

The  Anesthol-Ether  Sequence  by  the  Drop  Method. — In  the  anesthol- 
etlier  sequence,  as  well  as  in  the  ethyl  clilorid-ether  sequence,  a  factor  of 
safety  is  preliminary  medication  with  morphin.  The  New  York  Ger- 
man Hospital's  system  is  to  give  about  14  o^  a  grain  of  morphin  one- 
half  hour  before  narcosis.  Hellman,^  anesthetist  to  the  German  Hos- 
pital, prefers  pantopon,  %  of  a  grain  three-quarters  of  an  hour  before  the 
operation,  and  repeats  this  just  before  the  operation.  In  certain  selected 
cases  he  gives  j^q-  grain  of  hyoscin  with  the  first  dose.  Hellman  states 
that,  while  he  thoroughly  dislikes  morphin  before  anesthesia,  in  panto- 
pon he  has  a  safe  and  reliable  aid. 

ISTeef  states :  ^  "The  odor  of  the  anesthetic  may  become  markedly 
repugnant  to  those  who  have  previously  been  under  its  influence,  and 
assurance  on  this  point  may  help  to  bring  about  a  prompt  decision.  A 
few  drops  of  a  10  per  cent  emulsion  of  Persian  oil  of  rose  in  deodorized 
alcohol  on  the  mask  is  an  efficient  way  of  eliminating  this  disagreeable 
element  in  the  induction  of  anesthesia." 

Using  an  ordinary  chloroform  or  some  similar  mask,  the  anesthesia 
is  commenced  with  one  to  three  drops  of  the  oil  of  orange,  which  is  then 
followed  by  the  anesthol  and  continued  with  ether.  This  is,  in  the 
authors'  opinion,  safer  than  the  chloroform  or  ethyl  chlorid-ether  se- 
quence, and  much  safer  than  the  continuous  use  of  ether  by  the  drop 
method  for  the  following  reasons : 

First:  Anesthol  is  less  "smelly"  than  chloroform  or  ether,  and  for 
this  reason  no  doubt  is  less  irritating  to  the  upper  air  passages. 

Second:  The  anesthesia  is  induced  a  little  quicker  than  by  chloro- 
form. 

Third:  Both  experimental  and  clinical  experience  justify  the  state- 
ment that  next  to  nitrous  oxid  it  is  probably  the  safest  induction  anes- 
thetic. 

The  administration  is  conducted  as  follows:     With  the  mask  encir- 

^Neef,  R  E. :     "Surgical  Essentials,"  Am.  J.  Surg.,  April,  1912. 

-  Hellman,  A.  M. ;  "  The  Use  of  a  New  Opium  Preparation  Before  Anes- 
thesia— A  Preliminary  Note  with  a  Eeport  of  50  Cases, ' '  J.  Am.  Med.  Assn.,  Jan., 
1912,  n.  s.  7,  No.  1,  39-45. 

^  Loc.  cit. 


ETHER  209 

cled  by  a  towel,  the  anesthol  is  administered  drop  by  drop,  say  one  drop 
the  first  ten  seconds,  two  drops  the  next  ten  seconds,  etc.  As  soon  as 
the  patient  becomes  accustomed  to  the  anesthetic  vapor  the  drops  may  bo 
rapidly  increased.  If  the  patient's  breathing  is  shallow  a  few  drops  of 
ether  from  time  to  time  will  stimulate  and  keep  up  the  respiratory  fiiru;- 
tion.  As  the  stage  of  primary  anesthesia  or  unconsciousness  is  reached, 
the  ether  must  be  pushed  as  rapidly  as  the  condition  of  the  upper  air 
passages  of  the  patient  permits.  If  ether  is  given  at  this  time,  drop  by 
drop,  and  there  is  no  swallowing  reflex,  it  should  be  continued;  other- 
wise, if  there  are  swallowing  reflexes,  anesthol  may  be  continued  for  ten 
or  twenty  seconds  and  then  the  ether  recommenced. 

If  there  is  objection  made  by  the  patient  to  the  vapor  strength,  as 
indicated  by  the  turning  of  the  head  or  holding  of  the  breath,  the  mask 
may  be  slightly  lifted  from  the  face  and  then  replaced.  If  there  is 
marked  pallor  of  the  face,  and  the  pulse  is  weak  during  the  induction 
stage,  the  anesthol  should  be  immediately  replaced  by  ether.  Cyanosis 
should  not  be  allowed  during  the  induction  period.  If  this  occurs  a 
rearrangement  of  the  air  passages  by  moving  the  head  to  right  or  left, 
or  by  supporting  the  chin,  or  raising  slightly  the  lower  Jaw,  or,  in  elderly 
people,  supporting  the  alse  of  the  nose,  will  correct  this  trouble.  The 
usual  amount  of  anesthol  necessary  to  induce  anesthesia  when  morphin 
has  been  given  is  15  to  25  c.c. 

The  average  time,  when  morphin  or  some  preliminary  medication 
has  been  given,  is  five  minutes;  without  this  preliminary,  it  is  eight 
minutes.  When  properly  given  the  morphin-anesthol-ether  sequence  is 
induced  in  over  90  per  cent  of  cases  with  no  stage  of  excitement  what- 
ever. The  induction  stage  must  not  be  prolonged  too  long,  as  vomiting 
is  apt  to  occur. 

After  the  change  has  been  made  to  ether,  if  it  is  desirable  to  deepen 
the  anesthesia  for  any  reason,  instead  of  crowding  the  ether  and  thereby 
producing  unnecessary  salivation,  a  few  drops  of  anesthol  will  quickly 
and  safely  deepen  the  anesthesia,  without  the  salivary  gland  activity 
that  would  be  produced  by  an  amount  of  ether  sufficient  to  obtain  the 
relaxation  called  for. 

A  glance  at  the  statistics  for  the  anesthol-ether  sequence  will  fully 
convince  anyone  of  the  safety  and  desirability  of  this  sequence.  At  the 
German  Hospital,  in  the  year  1905,  149  cases  were  given  anesthesia  by 
this  method,  increasing  in  number  each  year  until  the  year  1911,  when 
there  were  919. 

The  Ether  Rausch.— Coughlin  ^  recently  described  the  "ether 
rausch."    We  quote  voluminously  from  Coughlin's  article. 

The  ether  rausch,  according  to  Coughlin,  was  used  in  this  country 
twenty-five  years  ago.     Lindner,  of  Dresden,  has  used  it  more  than  five 

^Coughlin,  William  T.:     J.  Am.  Med.  Assn.,  July  1,  1911,  17,  18. 


210  ANESTHESIA 

thousand  times.  Coiighlin  is  using  it  at  the  College  Clinic,  St.  Louis 
University  Medical  School.  He  reports  two  hundred  cases,  in  some  of 
which  he  acted  both  as  the  anesthetist  and   ()])orator.     The  only  fail- 


A.     Wire  Frame  of  the  Mask. 


C.     The  Frame  Covered  with  Oiled  Silk, 
Fig.  70. — The  Ether  Rausch. 

ures  were  in  patients  who  refused  to  proceed  beyond  the  first  two  or 
three  inhalations.  He  recommends  it  for  all  minor  surgical  operations 
that  can  be  better  done  if  the  patient  feels  no  pain,  such  as  opening 
abscesses,  setting  fractures,  reducing  dislocations,  and  removing  ingrow- 
ing toe-nails.  From  his  experience  he  states  that  it  is  contraindicated 
in  any  operation  which  requires  more  than  five  minutes'  time,  or  in 
those  in  which  general  relaxation  is  necessary.     Pale,  flabby  children. 


ETHER  211 

chronic  bronchitis,  emphysema,  marked  arteriosclerosis,  or  diseases  of 
the  pulmonary  or  cardiovascular  system  also  contraindicate  its  use. 
Coughlin  thinks  it  is  preferable  to  any  local  anesthetic  for  the  special 
cases  outlined.  In  many  cases  of  great  local  inflammation  the  injection 
of  a  hypodermic  needle  gives  almost  as  much  pain  as  the  relief  it  affords 
during  the  actual  incision.  The  ordinary  Esmarch  inhaler  is  not  satis- 
factory, as  it  does  not  allow  enough  ether  to  be  introduced  at  one  time 
to  produce  general  anesthesia  without  very  great  irritation  of  the  upper 
air  passages.  The  mask,  therefore,  must  be  a  large  one;  large  enough 
to  fit  the  outside  of  the  face.  Air  must  be  rigidly  excluded  as  far  as 
■possible.  An  ordinary  Derby  hat  has  been  frequently  used  by  Coughlin 
for  this  purpose.  It  is  placed  over  the  patient's  face  with  the  saturated 
ether  gauze  attached  to  the  crown  by  a  safety  pin.  Wet  towels  are  placed 
around  the  undersides  of  the  hat,  thus  excluding  all  air.  The  mask 
generally  used,  however,  is  a  very  large  wire  frame,  the  margin  of  which 
fits  closely  the  outer  margin  of  the  face.  A  pad  of  gauze  is  placed  at 
the  top  of  this  mask,  which  is  then  saturated  with  ether  and  then  the 
wire  frame  is  covered  with  oiled  silk,  the  points  of  contact  with  the  mask 
and  face  being  filled  in  with  the  wet  towels.  The  patient  is  told  that 
the  only  unpleasant  feature  is  the  smell  of  the  ether.  He  is  now  re- 
quested to  raise  his  arm  and  to  keep  it  raised  as  long  as  possible. 
After  placing  the  mask  over  the  face"  the  patient  is  told  to  breathe 
deeply.  At  about  the  twelfth  inhalation  the  arm  wavers  and  begins  to 
fall.  The  mask  is  removed  and  at  once  the  operation  is  begun  and 
quickly  finished.  The  patient  may  be  cyanosed  at  first,  but  this  quickly 
disappears,  and  he  comes  out  of  the  anesthetic  quietly.  In  the  particular 
case  related  by  Coughlin  the  patient  was  eating  dinner  twenty  minutes 
after  the  operation  was  concluded.^ 

The  Semi-Closed  Method. — The  drop  method  of  ether  just  described 
can  be  changed  quickly  into  the  semi-closed  method  in  the  following 
manner : 

Have  the  mask  with  towels  arranged  according  to  Davis's  method  for 
administering  drop  by  drop. 

Place  another  towel  around  the  mask  and  face  and  then  place  an 
additional  towel  over  the  opening  in  which  the  ether  is  dropjoed.  This 
will  insure,  more  or  less,  to-and-fro  breathing.  The  upper  towel  can  be 
removed  from  time  to  time,  when  half  a  dram  to  one  dram  of  ether 
may  be  poured  upon  additional  pieces  of  gauze  placed  upon  the  top  of 
the  mask.     The  upper  towel  is  now  to  be  quickly  replaced. 

The  rebreathing  will  continue  for  two  to  four  minutes,  when  ether 
may  be  again  added  and  the  towel  replaced  as  before.    This  procedure  is 

^  As  ethyl  chlorid  has  a  longer  stage  of  analgesia  than  any  other  inhalation 
anesthetic  theoretically,  at  least,  it  should  be  preferable  to  ether  for  the 
' '  rausch. ' ' 


212  ANESTHESIA 

indicated  when,  for  any  reason,  it  is  hard  to  maintain  a  proper  degree 
of  anesthesia  by  the.  ordinary  drop  method. 

Towel  and  Paper  Cones. — These  cones  are  still  used  in  a  great  many 
hospitals,  and  one  of  the  best  methods  of  making  them  is  described 
by  Miller  (providence,  E.  I.)  as  the  Handkerchief  Method,  and  is  fully 
illustrated. 

The  Handkerchief  Method  of  Administering  Ether. — "This  is  the 
result  of  a  search  for  a  simple,  clean,  and  otherwise  practical  appliance 
for  the  administration  of  ether  by  the  internes  of  hospitals.  It  has  been 
used  with  satisfaction  in  over  20,000  cases. 

"The  appliance  consists  of:  (1)  an  open  cone;  (2)  a  ring  of  sheet 
metal;    (3)  a  handkerchief  and  diaphragm  of  gauze. 

"The  cone  is  made  from  three  sheets  of  newspaper  folded  to  form  a 
strip  six  inches  wide.  (Fig.  71  A.)  This  strip  is  folded  upon  itself 
to  form  a  funnel  which,  when  flattened  out,  has  a  breadth  of  six  inches. 
(Fig.  71  B.)  The  funnel  is  covered  with  a  clean  towel  which  meas- 
ures about  eighteen  by  twenty  inches.  The  towel  is  placed  on  a  flat 
surface.  The  newspaper  funnel  is  placed  upon  the  towel  with  one  end 
of  the  funnel  at  the  middle  of  the  towel.  The  towel  is  folded  about  the 
outside  of  the  funnel.  (Fig.  71  C.)  The  long  end  of  the  towel  is 
pushed  through  the  funnel  (Fig.  71  D)  and  folded  over  the  end  of 
the  funnel.  (Fig.  71  E.)  The  short  end  of  the  towel  is  folded  inside 
the  funnel.     (Fig.  71  F.) 

"A  strip  of  yffo'  sheet  brass,  silver  plated,  two  inches  wide  and  fif- 
teen inches  long,  is  formed  into  a  ring  which  is  adjustable  in  size.  (Fig. 
71  G.)     The  ring  is  sterilized  by  boiling. 

"A  diaphragm  composed  of  eight  layers  of  No.  1  sterile  surgical  gauze 
is  placed  over  one  end  of  the  cone.  (Fig.  71  H.)  The  metal  ring  is 
adjusted  to  a  size  a  little  smaller  than  the  inside  of  the  cone.  It  is 
placed  over  the  diaphragm  and  pushed  inside  the  cone,  carrying  the 
diaphragm  to  the  full  depth  of  the  ring.  (Fig.  71  I.)  The  ring  is 
pulled  open  as  far  as  possible,  fixing  the  diaphragm  in  the  cone.  (Fig. 
71  J.)  There  is  thus  formed  a  chamber,  its  sides  formed  of  the  thin 
sheet  of  metal,  its  floor  formed  of  eight  layers  of  gauze,  and  its  roof  free. 
The  roof  of  this  chamber  is  the  distal  end  of  the  cone.  A  handkerchief 
of  No.  1  sterile  surgical  gauze  is  well  shaken  out  and  placed  in  the 
chamber.  (Fig.  71  K.)  The  two  sides  of  the  chamber  are  drawn 
together  and  held  by  a  safety  pin  passing  through  the  two  sides  of  the 
cone  close  to  the  metal  ring.  (Fig.  71  L.)  At  the  proximal  end  of 
the  cone  is  an  air  space  four  inches  deep.  The  temperature  in  this  space 
during  an  ordinary  administration  of  ether  is  about  88°  F.     (Fig.  71  M.) 

"Before  beginning  the  administration  of  ether  with  this  cone,  the 
gauze  handkerchief  is  drawn  partially  out  from  the  chamber,  leaving  a 
clear  airway  at  one  end  of  the  chamber.     (Fig.  71  L.)     On  the  gauze 


^ 


D 


Fig.  71a-f. — The  Handkerchief  Method. 


•■■A  .■■WKt  -M^  ^ 


K  L 

Fig.  71g-l. — The  Handkerchief  Method — Continued. 


^p^. ,.' 


fl 


f 


^v 


•^Ir 


^ 


N 


^ 


^ 


O 


Fig.  71m-o. — The  Handkerchief 


Method — Continued. 


216 


ANESTHESIA 


diaphragm  are  placed  a  few  drops  of  the  oil  of  orange.     The  proximal 
end  of  the  cone  is  fitted  to  the  patient's  face,  and  he  is  allowed  to  take 

several  breaths  through  the  cone. 
Ether  is  then  added  to  the  gauze 
handkerchief,  drop  by  drop,  until 
the  patient  has  become  accustomed 
to  the  vapor.  (Fig.  71  N.)  Then 
the  gauze  handkerchief  is  pushed 
into  the  chamber,  so  as  to  completely 
fill  it,  and  ether  is  added  gradually 
until  anesthesia  is  complete.  (Fig. 
71  0.) 

"If  this  proceeding  is  carried  out 
slowly  there  is  no  coughing,  choking, 
or  feeling  of  suffocation.  The  sup- 
ply of  air  necessary  for  respiration 
is  not  interfered  with,  and  the 
amount  of  ether  vapor  inspired  is 
imperceptibly  increased. 

"During  the  operation  ether  is 
added  constantly,  drop  by  drop,  or 
poured  on  the  handkerchief  fre- 
quently in  small  quantities,  at  the 
distal  end  of  the  cone,  or  through 
the  proximal  end,  on  removing  the 
cojie  momentarily  from  the  patient's  face.  The  handkerchief  is  frequently 
taken  from  its  chamber  and  shaken  out.     In  this  way  the  evaporating 


Fig.  72. — Cone  Adjusted  to  the  Face. 
There  is  ample  air  space  above,  and 
nose  space  below  the  frame.  Right 
hand  supports  the  chin,  to  prevent 
relaxation  of  the  jaw  and  prolapse  of 
the  tongue.  Left  hand  folds  the  top 
of  cone  to  increase  the  amount  in- 
spired. (Gallant:  Med.  Record,  Dec, 
1899.) 


'^^^-^    \ 


Fig.    73. — Allis    Inhaler    with    Soft      Fig.  74. — Allis  Inhaler,  Metal  with 
Rubber     Cover     for     Semi  -  open  Rubber    Cushion    for    Face    and 

Method.  Gauze  Diaphragm, 


ETHER 


217 


Fig.  75. — The  Esmarch 
Inhaler. 


surface  is  kept  free  and  the  amount  of  ether  remaining  on  the  handker- 
chief is  frequently  noted.     The  eyes  are  not  covered. 

"The  handkerchief  method  has  the  following  theoretical  advantages : 
(1)  simplicity;  (2)  cleanliness;  (3)  continuous  administration  of 
ether;  (4)  evaporating  surface  at  some  distance 
from  the  patient's  face;  (5)  no  interference  with 
free  air  supply;  (6)  warmed  ether  vapor;  (7) 
steady,  constant  control  over  the  amount  of 
ether  vapor  inspired;  (8)  economy;  no  ether  is 
wasted  by  soaking  into  the  cone,  or  by  running 
down  the  neck  of  the  patient. 

"This  method  has  also  the  following  practical 
advantages : 

"(1)  Inexperienced  anesthetizers  have  been 
quickly  taught  to  use  the  method  satisfactorily. 

"(3)  Anesthetizers  who  have  been  accustomed 
to  the  use  of  other  methods  have  all  preferred  the 
handkerchief  method  after  a  short  trial. 

"(3)  Patients  who  have  taken  ether  badly  in 
other  ways  have  been  smoothly  anesthetized  by  the 
handkerchief  method." 

When  using  these  cones,  or  any  other  semi-closed  or  closed  method 
of  ether,  it  is  always  best  to  begin  the  administration  with  an  open  mask 
by  pouring  one  or  two  drops  of  the  oil  of  orange  and  then  proceed- 
ing to  the  drop  method  as  described  by  Dr.  Davis.  As  the  patient 
reaches  surgical  anesthesia,  change  to  the  cone  mask,  upon  which  has 
been  placed  one  or  two  drams  of  ether;  continue  adding  the  ether  from 
time  to  time  as  the  condition  of  the  patient  demands. 

The  Closed  Method.— 
The  closed  method  of  ad- 
ministering ether  was  the 
immediate  precursor  of  the 
gas-ether  sequence.  It  was 
developed  in  England  in 
1872,  and  has  been  em- 
ployed successfully  in  thou- 
sands of  cases  since  that 
time.  Dr.  Clover  was  the 
first  to  develop  an  appara- 
tus that  received  extensive  recognition.  As  the  method  of  administration 
is  the  same  with  any  mask  and  bag,  regardless  of  the  name  of  the  in- 
haler, directions  will  be  given  suitable  for  any  apparatus  that  may  be 
used. 

Any  inhaler  for  the  administration  of  the  nitrous  oxid-ether  se- 


FiG.  76. 


-Comparative  Size  of  Bores  op 
Inhalers   (Luke). 


218 


ANESTHESIA 


Fig. 


77. — Bennett's    Nithous  Oxid-Ethek    Ap- 
PAKATUs:     Ether  Inhaler. 


Fig. 


Fig. 

of  a 
gas 


quence  should  have  a  large 
bore.  The  two  illustra- 
tions takeu  from  Luke 
make  further  comment 
unnecessary. 

The  Nitrous  Oxid- 
Ether  Sequence. — The  ni- 
trous oxid-ether  sequence, 
■\vhic]i  consists  in  giving 
one  or  two  bags  full  of 
gas  and,  while  the  patient 
is  unconscious,  gradually 
turning  on  the  ether,  was 
probably  introduced  into 
this  country  by  Thomas 
Bennett,  of  New  York 
City. 

The  Bennett  In- 
haler. —  This  apparatus 
consists  of  a  face-piece 
with  a  rubber  cushion,  a 
gas  cylinder  and  a  cylin- 
der for  holding  the  valves 
used  in  administering  gas, 
and  two  bags.  The  ap- 
paratus can  be  taken  apart 
and  used  for  the  closed 
administration  of  ether 
alone,  or  for  gas  and  air, 
or  for  the  gas-ether  se- 
quence. Nearly  all  of  the 
gas  -  ether  apparatus  in 
A  m  e  r  i  c  a  are  probably 
modifications  of  this  in- 
haler. 

The  Gwathmey  In- 
haler. —  The  Gwathmey 
inhaler,  for  the  adminis- 
tration of  the  nitrous 
oxid-ether  sequence,  is  a 
modification  of  the  Ben- 
nett inhaler.  It  consists 
face-piece  A\dth  expiratory  valves,  one  cylinder  for  the  passage  of 
alone  or  through  ether,  or  the  continuance  of  the  administration 


78. — Bennett's 

RATUS: 


Nitrous  Oxid-Ether 
Gas  Inhaler. 


Appa- 


79. — Bennett's  Nitrous  Oxid-Ether 
RATUS :     Gas  and  Ether  Inhaler. 


Appa- 


ETHER 


219 


with  ether  alone  by  the  closed  method,  and  a  ohimnoypjeee  contain- 
ing an  inspiratory  and  expiratory  valve.  These  valves  can  be  easily 
pulled  out  of  the  way  by  a  sliding  collar,  so  tliat  to-and-fro  l)reathi])g 


Fig.  80. — The  Gwathmey  Inhaler  Open. 

can  be  instituted  at  any  time.  A  rubber  bag  is  attached  to  this  chim- 
neypiece.  At  the  other  end  of  the  bag  a  rubber  tube  with  a  stop- 
cock connects  the  bag  to  the  gas  cylinder.  If  the  Gatch  method 
of  administration  of  gas  and  oxygen  is  to  be  used,  a  Y-piece  con- 
nects tbe  nitrous  oxid  and  oxygen  cylinders  to  the  bag.  The  appara- 
tus is  reduced  in  weight 
and  bulk  to  nearly  one- 
half  that  of  the  Bennett 
apparatus,  having  one 
cylinder  and  one  bag.  The 
object  of  the  nitrous  oxid- 
ether  sequence  is  to  avoid 
the  first  and  second  stages 
of  ether  narcosis  with  its 
preliminary  excitement, 
struggling,  coughing,  hold- 
ing the  breath,  swallowing, 
and  all  other  disagreeable 
and  disgusting  effects  that 
were  formerly  connected 
with  this  stage  of  etheriza- 
tion, and  to  enter  imme- 
diately into  the  third  stage  for  surgical  anesthesia.  The  patient  is 
thus  enabled  to  take  advantage  of  one  of  the  safest  general  anesthetics 


Fig.  81. — The  Gwathmey  Inhaler  Closed 


220 


ANESTHESIA 


in  the  most  agreeable  manner  possible,  and  with  the  least  physical  and 
nervous  strain.  It  is  the  exception  for  the  patient  to  show  any  excite- 
ment whatever,  and  deep  anesthesia  is  generally  reached  in  about  three 
minutes.  ■ 

The  Fueniss  Gas-Ether  Inhaler. — This  iidialer  consists  of  exactly 
the  same  number  of  pieces  as  the  Gwathmey  inhaler,  and  differs  only  in 


Fig.  82. — Gwathmey  Nitrous  Oxid-Ether  Apparatus. 


minor  details.  In  purchasing  any  apparatus  for  the  administration  of 
nitrous  oxid  and  ether  in  sequence,  the  purchaser  should  bear  in  mind 
one  general  rule  governing  the  safety  of  the  method  of  administration, 
and  that  is  the  size  of  the  aperture  through  which  the  patient  breathes. 
(See  Fig.  76.) 

As  the  technique  for  the  administration  of  the  gas-ether  sequence  is 
practically  the  same  for  all  three  inhalers,  general  directions  applicable 
to  all  three  inhalers  follow. 

The  distinctive  feature  of  the  Gwathmey  gas-ether  inhaler  is  that, 
as  the  ether  chamber  is  turned  on,  the  ether  can  escape  into  the  bag  only 
— the  opening  toward  the  patient's  face  being  still  closed.     This  con- 


ETHER 


221 


tinues  until  the  ether  chamber  is  one-half  on,  at  which  time  it  begins  to 
show  at  the  opening  toward  the  patient's  face.  The  patient  thus  gets  a 
more  uniform  and  diluted  ether  vapor  than  if  both  openings  of  the 
ether  chamber  appeared  at  the  same  time.  This  makes  it  possible  to 
make  the  change  to  ether  without  the  patient  swallowing  or  showing 
other  recognition  of  the  change. 

The  Davis  Inhaler. — This  inhaler  is  for  the  gas-ether  sequence  or 
the  ethyl  chlorid-ether  sequence;  the  ether  in  every  instance  is  given  by 
the  drop  method.  The 
apparatus  is  a  perfect 
one  for  the  purposes 
for  which  it  is  used. 
Davis  was  probably 
the  first  in  America 
to  get  out  an  appara- 
tus for  the  adminis- 
tration of  ether  by  the 
closed  drop  method. 

Technique  of  the 
Nitrous  Oxid-Ether 
Sequence. — First:  Fill 
the  rubber  bag  with 
gas.  It  is  well  to 
have  the  gas  bag  at- 
tached to  the  nitrous 
oxid  cylinder  through- 
out the  operation,  so 
that  a  change  can  be 
made  in  the  gas  mix- 
ture   or    additional    nitrous    oxid    added    to    the    bag    at    any    time. 

Second:  Place  two  to  four  drams  of  ether  in  the  ether  chamber. 
Be  careful  to  have  the  ether  chamber  so  arranged  that  the  odor  will  not 
penetrate  the  face-piece  or  other  chambers  of  the  inhaler. 

Third :  See  that  the  air  cushion  on  the  face-piece  is  partly  inflated. 
If  this  cushion  is  too  tightly  inflated  it  will  not  be  as  effective  in  exclud- 
ing the  air  as  when  it  is  only  partly  inflated. 

Fourth:  Place  the  mask  gently  upon  the  patient's  face,  having  first 
removed  all  pillows.  Have  the  patient  breathe  through  the  valves  or 
airway  once  or  twice  before  turning  on  the  gas.  Wlien  the  gas  is 
turned  on,  it  should  enter  the  inhaler  quietly.  (It  will  not  do  this  if 
the  bag  is  overdistended.)  Have  the  patient  breathe  one  bag  of  gas 
through  valves.  Then  turn  to  to-and-fro  breathing,  and,  if  necessary, 
refill  the  bag  again  with  gas.  The  patient  will  now  be  unconscious, 
provided  no  air  has  been  allowed  to  enter  the  inhaler  between  the  face 


Fig.  83. — The  Furniss  Nitrous  Oxid-Ether  Apparatus. 


222 


ANESTHESIA 


and  mask  or  any  other  part  of  the  apparatus.  Now  hegin  turning  on 
the  ether  very,  very  slowly.  If  the  patient  coughs,  swallows,  or  holds 
the  breath,  turn  off  the  ether  and  allow  a  little  rebreathing,  and  then 
begin  with  the  ether  again.  If  the  patient  still  rebels,  more  nitrous 
oxid  should  be  added  in  the  bag.    When  the  ether  chamber  is  on  full 

the  patient  should  be  in  deep  sur- 
gical anesthesia,  which  should  be  in 
from  two  to  three  minutes,  depend- 


FiGS.    84    and  85. — The  Davis  Apparatus,  Showing  Inhaler  for  Ethyl  Chlohid- 
Ether  Sequence  by  the  Closed  Drop  Method. 


ing  upon  the  patient.  Surgical  anesthesia  is  usually  indicated  by  a  slight 
snore.  A  breath  of  air  may  now  be  admitted  by  raising  the  mask  from 
the  face  on  inspiration  and  replacing  again  so  as  to  catch  the  expiration 
of  the  patient  in  the  bag.  The  expired  air  thus  passes  through  the  ether 
chamber  and  keeps  the  bag  full  of  warm  ether  vapor.  A  breath  of  fresh 
air  may  be  admitted  every  two  to  six  breaths,  according  to  the  condition 
of  the  patient.  One  or  two  drams  of  ether  poured  from  the  container  into 
a  minim  glass  should  be  added  every  two  and  one-half  minutes.  This  may 
be  necessary  for  the  first  five  or  ten  minutes;  after  that,  a  dram  every 
three  minutes  will  be  all  that  is  necessary  with  the  majority  of  patients. 
In  very  cold  weather  it  is  always  best  to  place  the  inhaler  upon  a 


ETHER 


223 


radiator  or  stove  or  in 
front  of  a  register,  or  to 
dip  it  in  hot  water  before 
commencing  the  a  n  e  s  - 
thesia. 

Caution!  With  any 
closed  inhaler  never  alloiv 
the  hag  to  become  deflated, 
otherwise  the  patient  at- 
.tempts  to  hreaihe  from  the 
vacuum,  and  a  tremendous 
strain  is  immediately 
thrown  upon  the  respira- 
tory and  circulatory  sys- 
tems, resulting  in  shock 
and  collapse,  if  unnoticed. 
Nitrous  Oxid  -  Ether  - 
Chloroform  Sequence. — 
For  all  operations  lasting 
over  one  hour  it  is  well  to 
change  to  chloroform  or 
ether  on  an  open  mask  for 
the  last  ten  or  fifteen  min- 
utes. The  change  to  chlo- 
roform should  be  made 
when  the  reflexes  are 
slightly  active.  Very  small 
amounts  of  chloroform 
will  be  necessary  to  main- 
tain the  narcosis.  If  at 
any  time  the  patient  be- 
comes pale  or  shows  signs 
of  shock  from  any  cause, 
ether  by  the  drop  method 
should  be  immediately 
substituted  for  the  chloro- 
form. The  indications  for 
a  change  from  the  closed 
method  to  the  open  would 
be  rapid  respirations  or 
marked  cyanosis.  Deep 
anesthesia  is  easily  and 
safely  maintained  with 
ether  by  the  closed  method. 


Fig.    86. — Davis   Apparatus   for   Gas-Ether   or 
Ethyl  Chlorid-Ether  by  Drop  Method. 


Fig. 


87. — Davis   Heaters    for    Ether    or    Ni- 
trous Oxid  and  Oxygen. 


224 


ANESTHESIA 


The  pulse  is  usually  full  and  bounding,  the  respirations  are  deep,  and 
the  face  is  flushed.  Unless  the  change  to  chloroform  is  made  toward 
the  close  of  the  operation,  the  patient  does  not  usually  come  out  of 


^^4Mf.Jl^       'Y^ 

^1 

jmt-i^m  t0^m^^ 

'l 

r ..sail- ...iff   '^  ^:-i^''Z 

a 

V. 

bI            *  i^hI^^^B 

Fig.  88. — Davis  Heater  with  the  Gwathmey  Three-Bottle  Vapor  Inhaler. 

this  method  of  anesthesia  as  quietly  as  if  this  change  had  not  been 
made.  There  does  not  seem  to  be  the  danger  attached  to  the  adminis- 
tration of  chloroform  in  this  way  after  the  circulatory  and  respiratory 


A.  B. 

Fig.  89. — Vapor  Mask.  A.    The  mask,  one-third  size.  B.    Rubber  covering  for  the  mask, 
which  helps  to  prevent  cooling  and  waste  of  the  anesthetic. 

centers  have  been  stimulated  by  the  nitrous  oxid  and  ether.  The 
change  to  chloroform  may  be  made  immediately  after  reaching  full 
ether  anesthesia  if  for  any  reason  it  is  desired  to  give  the  smallest 
amount  of  ether  and  at  the  same  time  avoid  the  dangers  of  the  initial 
stages  of  chloroformization. 


ETHER 


225 


The  Vapor  Method  of  Anesthesia.^ — The  vapor  method   is  one  in 
which  air,  oxygenated  air,  oxygen,  or  other  gas  passes  either  over  or 


Fig.  90. — Top  of  Three-Bottle  Vapor  Inhaler. 


through  the  anesthetic  agent,  or  the  anesthetic  is  allowed,  to  drip  into  the 
current  of  air  and  is  thus  vaporized  before  heing  delivered  to  the  pa- 
tient. The  term  distin- 
guishes it  immediately  £rom 
the  drop  method,  where  the 
anesthetic  is  placed  upon 
gauze  or  other  material  and 
is  vaporized  by  the  patient. 

When  the  vapor  is  car- 
ried by  tube  to  the  pharynx 
or  trachea  it  is  called  endo- 
pharyngeal  or  endotracheal 
insufflation,  the  word  insuf- 
flation meaning  "the  blow- 
ing of  powder  (or  gas)  into 
a  cavity."  ^ 

Endopharyngeal,  endo- 
tracheal, and  rectal  anes- 
thesia are  modified  forms  of 
the  vapor  method  of  admin- 


FiG.  91. 


-Dl^gram  of  Top  of  Three- 
Bottle  Inhaler. 

^  For  a  discussion  of  the  vapor  method  by  chloroform,  see  Chapter  VII. 
'  Gould :     ' '  Medical  Dictionary. ' ' 


226 


ANESTHESIA 


istration.  Junker's  small  chloroform  bottle,  operated  by  a  hand  atomizer, 
was  probably  the  first  vapor  apparatus.  The  reasons  for  the  evolution  of 
the  administration  of  ether  from  the  drop  and  cone  to  the  vapor  method 
have  been  aptly  described  as  follows :  "Until  within  a  very  few  years  ether 
has  suffered  from  an  evil  reputation  with  patients  despite  its  indescriba- 
ble beneficence.    This  reputation  has  been  due  in  no  small  degree  to  the 


Fig.  92. — Jackson's  Speculum  in  Position  for  the  Introduction  of  the  Endotracheal 
Catheter.     Note  the  position  of  the  patient's  head.     (See  p.  428.) 


manner  of  its  administration.  The  liquid  ether  has  been  poured  or 
dropped  on  a  sponge  or  other  absorbent  material,  and  the  sponge  placed 
in  a  glass,  metal,  or  rubber  container  called  a  cone.  This  in  turn  was 
placed  more  or  less  insistently  and  abruptly  over  the  mouth  and  nose, 
and  inhalation  of  the  suffocating  fumes  forced  until  unconsciousness 
ensued.  Such  a  proceeding  had  everything  to  make  it  intolerable  to 
the  sufferer,  and  was  endured  only  to  afford  escape  from  a  greater 
horror — the  pain  of  operation." 

Warmed  Ether  Vapor.^ — Ether  vapor  may  be  delivered  to  the  patient 
warmed  to  room  or  body  temperature,  as  conditions  demand,  by  so 
many  different  methods  that  there  is  no  longer  a  question  of  the  pa- 

^  For  detailed  discussion  of  warming  the  anesthetic  vapor,  see  p.  71. 


ETHER 


227 


tient's  inhaling   a  warmed   vapor.      The   value   of   employing  warmed 
ether  vapor  is,  however,  still  douhted  hy  some  practitioners. 

When  the  closed  vapor  method  is  used  the  temperature  of  the  ether 
vapor  is  increased  to  from  ten  to  twenty  degrees,  so  that,  when  inhaled. 


Fig.  93. — Endopharyngeal  Tubes  for  Maintaining  Insufflation  Anesthesia. 

(Lumbard.) 

the  vapor  is  practically  at  room  temperature.  With  the  open  method 
the  ether  vapor  is  usually  warmed  by  being  passed  over  or  through  hot 
water.  The  condition  of  the  patient,  the  season,  and  the  locality  de- 
termine whether  or  not  the  vapor  should  be  warmed.  A  patient  whose 
vitality  is  exhausted,  and  who  may  be  already  in  a  state  of  shock,  needs 
artificial  heat  from  every  source  to  prevent  a  further  decrease  in  body 


Fig.  94. — Glass  Nasal  Tubes  for  General  Anesthesia.       (Lumbard.) 


temperature.     On  the  other  hand,  it  would  be  entirely  unnecessary  to 
heat  the  vapor  for  any  ordinary  operation  during  very  hot  weather. 

Between  these  two  extremes  there  is  a  mean  of  temperature  (usu- 
ally room  temperature),  at  which  experience  has  taught  that  all  re- 
quirements of  safe  anesthesia  are  met. 


228 


ANESTHESIA 


It  may  be  of  interest  in  this  connection  to  note  the  experience  of 
other  observers. 

Lawen  ^  is  convinced  that  chilh'ng  is  one  of  the  essential  contributing 


Fig.  95. — Junker  Inhaler.     (1)   Uncovered  mask  and  hand  pump  attached.     (2)  Vapor 
mask  covered.     (3)  Tubes  for  mouth  work.     (4)  Sponge  holder. 

factors  to  post-operative  complications.  In  twenty-seven  reported  cases 
with  an  apparatus  for  warming  the  fumes,  the  results  were  excellent. 

Joss  ^  finds  that  ether  cools  the  air  inhaled  33°  to  44°  below  the 
temperature  of  the  room.     The  cooled  air  undoubtedly  lowers  the  re- 

"■  Munch,  med.  Woch.,  Oct.  3,  1911,  58,  No.  40,  2097. 

^  Mitteil.  Grenz.  Med.  und  Chir.,  Jena,  1911,  2^,  528. 


ETHER 


229 


sisting  powers  of  the  cilia  of  the  ciliated  epitlieliimi  Wn'ing  the  upper 
air  passages,  when  these  passages  become  chilled.  Infection  is  more 
liable  to  find  its  way  into  the  finer  air  passages,  as  salivation  increases 
under  the  chilled  anesthetic. 


Fig.  96. — Lumbaed's  Glass  Nasal  Tubes    (A    and    B).    Same   Attached    to    Drum 
FOR  Drop  Method  of  Ether-Chloroform  (C). 

Hervey,^   after  demonstrating  that  ether  is  warmed  when   inhaled 
by  the  patient,  sums  up  his  experience  with  warmed  ether  as  follows: 

"(1)  The  administration  of  ether  vaporized  at  a  distance  from  the 
patient,  the  so-called  closed  method,  is  a  distinct  advance, 
whether  warmed  or  not. 

"(3)  The  vapor  acts  with  increased  rapidity  proportional  to  its 
warmth. 

"(3)  Placid  breathing,  resembling  natural  sleep  during  anesthesia,  is 
often  an  index  of  nerve  competence,  and  this  efficiency  is 
weakened  and  disturbed  by  algid  anesthetic  irritations. 

"■N.  Y.  Med.  J.,  Feb.  15,  1913. 


Fig.  97. — Three-Bottle  Vapok  Apparatus  Connected  with  Electric  Heater  and 

Vapor  Mask. 


Fig.  98.- 


-FooT  Pump  Attached  to  Three-Bottle  Vapor  Inhaler 
through  hollow  tubes  welded  to  mouth-gag. 


The  vapor  passes 


ETHER  231 

■(4)   Ether  amounts  will  average  less  than  hy  other  methods,   as 

shown  by  statistics  of  hospital  expense. 
"(5)    Patients  awaken  with  less  distress  and  with  a  marked  favorable 

difference  in  appearance. 
'(6)   It  is  suitable  for  extreme  infancy  and  old  age. 
■(7)   Dryness  of  the  throat  is  never  complained  of  unless  oxygen 

has  been  added. 


Fig.  99. — Gwathmey  Method  of  Administeuing  \\  ahmed  Vapob  Through  the  Nose, 

"(8)  Cold  produces  the  so-called  irritation  of  ether,  contributing  to 
nausea,  vomiting,  and  shock,  delays  the  return  to  nutrition, — 
disturbing  the  stomach  by  ingestion  of  ether-laden  secre- 
tions,— and  annoys  the  patient  by  leaving  a  lingering  after- 
taste on  the  breath,  due  to  impairment  of  the  eliminative 
functions  of  the  mucous  membranes. 

"(9)  The  vapor  warmed  in  some  way  loses  a  portion  of  its  odorifer- 
ous strength  and  persistence,  to  the  relief  alike  of  anesthetist, 
surgeon,  and  patient." 

He  also  states  that  "it  requires  no  expert  observer  favorably  to  con- 
trast the  natural  and  placid  breathing  of  a  patient  anesthetized  by 
warm  vapor  with  that  of  one  whose  membranes  are  swollen  and  awash 
from  the  irritation  of  algid  inhalations." 


VAPOR 

The  Open  Method. — Wlien  the  open  method  is  indicated  the  vapor 
mask  is  used.  The  latest  model  consists  of  a  close-fitting  mask,  the 
base  of  which  is  a  hollow  tube  with  perforations  inside  so  that,  as  the 
vapor  is  pumped  either  by  foot  or  by  an  electric  motor,  or  passed  from  an 
oxygen  or  air  tank  through  the  apparatus,  the  patient  inhales  a  certain 


232 


ANESTHESIA 


known  percentage  of  the  anesthetic  and  gets  only  this  percentage,  re- 
gardless of  the  depth  or  rate  of  respiration.  The  upper  part  of  the  mask 
is  modeled  after  the  Yankaiier,  and  is  made  of  wire  gauze.    The  mask  is 


Fig.  100. — Ether  Vapor  Mask  Encircled  by  a  Towel  Held  in  place  by  a  Safety  Pin. 


Fig.  101. — Same  as  Figure  100  with  Outer  Fold  of  Towel  Dropped  as  Patient 
Reaches  Surgical  Anesthesia. 


usually  surrounded  by  a  towel,  the  object  of  which  is  to  decrease  the 
amount  of  ether  vapor  blown  away,  to  reduce  the  quantity,  and  to  in- 
crease the  safety,  by  warming  the  vapor  by  the  slight  amount  of  re- 


breathing  thus  obtained. 


Fig.  102a 


Fig.  102b. 


Figs.  102a  and  102b. — Methods  of  Holding  Jaw  Forward  so  as  to  Maintain  an 

Open  Airway. 


234 


ANESTHESIA 


Where  the  mouth  is  necessarily  open  during  long  operations  upon 
the  nose  or  mouth,  the  mouth  gag  with  hollow  tubes  attached  or  a  hol- 
low tube  may  be  substituted  for  the  vapor  mask  just  referred  to.  or 
pharyngeal  tubes  may  be  used. 

Small  children  and  weak  anemic  men  or  women  can  be  easily  anes- 
thetized by  the  open  method  of  vapor  alone.  Ordinarily  it  is  best  to 
commence  by  the  drop  method  and  switch  to  the  vapor  as  the  patient 
reaches  surgical  anesthesia.  If,  however,  the  vapor  alone  is  to  be  relied 
upon,  the  anesthetist  proceeds  as  follows:     Air  is  pumped  vigorously 


Fig.  103. — Pinneo's  Ether  Vapor  Apparatus,  Disconnected. 


through  the  bottle  marked  air  or  water.  The  index  should  now  be  grad- 
ually turned  toward  chloroform.  If  the  patient  coughs,  sneezes,  or 
holds  his  breath,  the  index  should  be  turned  back  again  and  a  fresh 
start  made.  Continue  in  this  way  until  the  patient  is  well  under  the 
anesthetic,  when  ether  may  be  substituted  for  the  chloroform  in  the  same 
manner.  If  the  patient  is  a  child,  and  if  there  is  a  suggestion  of  status' 
lymphaticus  or  other  contraindication  to  chloroform,  ether  may  be 
placed  in  the  small  chloroform  bottle,  and  the  gradual  change  to  ether,  as 
just  described  for  chloroform,  made.  As  the  patient  becomes  accus- 
tomed to  this  mild  vapor  the  stopcock  may  be  very  gradually  turned 
to  the  larger  ether  bottle. 

For  strong,  vigorous  adults  or  alcoholics  ether  from  the  small  bottle 
may  not  be  sufficient  to  get  the  patient  under  quietly  and  easily.  In 
this  instance  the  vapor  miy  be  supplemented  by  drops  of  chloroform 
or  ether  upon  the  vapor  mask.  After  the  patient  is  well  under  surgical 
anesthesia  it  will  be  easy  to  hold  him  with  the  vapor  alone. 

Most  elderly  patients  do  better  with  the  combination  of  ether  and 
chloroform  than  with  any  other  anesthetic.  When  this  is  so,  the  index 
must  be  turned  to  a  place  between  ether  and  chloroform  and  such  a  com- 


ETHER 


235 


bination  of  these  drugs  maintained  as  will  satisfy  all  given  require- 
ments.^ 

Pinneo  has  devised  a  very  useful  apparatus  for  vapor  anesthesia,  the 
vapor  being  heated  by  an  ordinary  clec^tric  bulb. 

Endopharyngeal  Anesthesia. — Karl  Connell  was  the  first  to  report 
a  large  number 
of  cases  by  this 
method.  We 
quote  voluminous- 
ly from  his  paper 
on  automatic 
pharyngeal  anes- 
thesia : 

"In  view  of 
the  objections  to 
the  endotracheal 
delivery,  I  have 
been  led  to  seek 
a  method  which 
would  overcome 
the  necessity  of 
intubation  and 
the  dangers  of  a 
badly  supervised 
delivery,  yet  pre- 
serve the  feature 
most  desired  for 
routine  anes- 
thesia, to  wit,  an 
automatic,  even, 
accurate,   and 

effective  delivery  of  the  anesthetic  agent.  In  the  pharyngeal  insufflation 
method  of  large  volumes  of  dilute  anesthetic  agent  deep  into  the  pharynx, 
I  believe  we  have  such  a  method.  The  delivery  is  established  after  full 
surgical  relaxation  has  appeared  by  face-mask  methods.  Speaking  now  of 
ether  vapor  in  air  delivery,  the  essential  feature  of  this  pharyngeal  method 
is  that  a  volume  of  air  is  insufflated  by  positive  pressure  into  the  lower 
pharynx,  a  volume  sufficient  to  provide  entirely  for  each  inspiration,  with- 
out any  air  being  inhaled  by  nose  or  mouth,  and  a  volume  bearing  a 
known  percentage  of  ether  vapor  in  the  greatest  dilution  which  will  hold 
that  patient  evenly  and  safely  anesthetized  for  the  operation  in  hand. 

^  For  additional  literature  relating  to  the  subject  of  vapor  anesthesia,  see 
Cullom:  J.  Am.  Med.  Assn.,  Sept.  21,  1912,  1114;  Hervey:  N.  Y.  Med.  J., 
Nov.  9,  1912;  and  Pinneo:     J.  Am.  Med.  Assn.,  Nov.  23,  1912,  1862. 


Fig.  104. — Pinnbo's  Ether  Vapor  Apparatus  in  Use. 


236 


ANESTHESIA 


"The  delivery  is  accomplished  by  preference  through  two  catheters 
inserted  one  through  each  nostril  a  distance,  on  the  average,  of  12  cm. 
"The  proper  distance  to  insert  each  catheter  is  the  distance  measured 


Fig.  105. — Pinneo's  Mouth  Tttbe  for  Conthstdous  Vapor  Anesthesia. 


Fig.  106. — Endoph.vryngeal  Insufflation  and  Mouth  Tube  Combined. 

off  on  the  tube  from  its  eyelet,  from  the  auditory  meatus  to  the  ala  nasi 
on  that  side.  This  carries  the  tube  well  into  the  lower  pharynx,  but  not 
into  the  esophagus. 

"The  catheters  selected  for  the  adult  are  size  18,  F,  soft  rubber. 


ETHER  237 

velvet  eye,  with  accessory  eyelet.  These  are  attached  to  a  Y  metal  de- 
livery tube  with  bent  prongs  for  convenience  of  placement  and  to  ])rc- 
vent  angulation  and  to  hold  the  catheters  in  place.  This  Y  tube  accu- 
rately fits  the  nose  and  forehead^,  and  is  held  in  place  by  adhesive 
plaster  strapped  across  the  brow. 

"The  volume  insufflated  is  such  as  to  entirely  supply  the  needs  of 
inspiration  without  extraneous  dilution.  This  requires  18  liters  of  air 
per  minute  for  the  average  adult,  into  which  is  vaporized  the  ether." 

The  essentials  of  endopharyngeal  anesthesia,  according  to  Connell, 
are  as  follows: 

"First:  The  ether  tension  in  the  arterial  blood  to  the  sensorium  is 
the  determining  factor  of  anesthetization. 

"Second :  This  tension  is  established  by  maintaining  in  the  alveolar 
air  during  preliminary  narcosis  an  ether  content  of  from  30  to  45  per 
cent  by  weight  to  air  under  conditions  at  sea  level,  an  equivalent  in 
pressure  of  from  119  to  182  mm.  of  mercury.  During  the  early  stage  of 
anesthesia,  say  for  the  first  twenty  to  forty  minutes,  this  tension  must 
be  maintained  by  percentages  scaling  from  26  down  to  15  per  cent. 
After  the  establishment  of  anesthetic  saturation  of  the  body,  it  is  main- 
tained at  about  the  latter  percentage,  the  equivalent  of  an  ether  pressure 
of  48  mm.  in  the  alveolar  air. 

"Third:  These  figures  probably  hold  for  the  entire  animal  kingdom, 
the  variable  factors  seen  in  ordinary  etherization  being  these :  Firstly, 
the  rapidity  with  which  the  body  is  brought  to  complete  anesthetic 
saturation,  as  determined  by  the  efficiency  with  which  the  ether  tension 
in  the  alveolar  air  is  maintained  by  fresh  delivery,  by  diffusion,  and  by 
tidal  movement;  secondly,  the  rapidity  of  blood  circulation;  thirdly, 
the  bulk  of  the  particular  body  to  be  saturated  and  the  capacity  of  that 
body  for  storage  and  destruction  of  the  ethyl  radical. 

"Fourth :  The  zones  of  anesthesia  above  and  below  this  saturation  or 
anesthetic  tension  point  are  already  well  established  for  man.  ^Yith 
absolute  certainty  as  to  the  outcome,  man  may  be  placed  in  an  ether 
atmosphere  of  the  percentage  of  ether  or  vapor  pressure  required  to  pro- 
duce deep,  medium,  or  light  anesthesia. 

"Fifth :  The  zone  of  surgical  relaxation,  i.  e.,  an  ether  pressure  of 
45  to  50  mm.,  is  a  zone  for  many  hours  devoid  of  danger  by  ether  intoxi- 
cation. 

"When  one  links  these  evident  advantages  of  a  full  and  continuing 
knowledge  of  the  dose  delivered,  with  the  advantage  of  an  even,  auto- 
matic, unwearying,  impersonal  machine  delivery  of  the  anesthetic  agent 
and  its  menstruum,  the  combination  works  for  ideal  anesthesia. 

"For  anesthesia  to  be  maintained  automatically,  at  the  same  time 
safely,  with  uniform  success,  requires  that  three  factors  be  under  the 
control  of  the  operator  or  anesthetist:     Firstly,  that  complete  prelim- 


238  ANESTHESIA 

inary  relaxation  of  the  individual  be  secured;  secondly,  that  the  anes- 
thetic agent  and  its  menstruum  be  so  delivered  as  to  be  freely  available 
for  respiration;  thirdly,  that  the  delivery  be  of  such  volume  as  to  en- 
tirely supply  the  needs  for  respiration,  as  well  as  of  such  accurately 
measured  and  known  percentage  or  tension  of  anesthetic  as  to  hold  a 
given  individual  safely  and  evenly  anesthetized. 

"For  delivery  to  become  automatic  the  anesthetic  agent  and  its 
menstruum  must  be  made  freely  available  for  inspiration  by  the  delivery 
passing  the  chief  obstruction,  namely,  the  base  of  the  tongue.  Full 
preliminary  anesthesia  is  best  accomplished  by  face-mask  methods,  since 
man  will  not  tolerate  the  introduction  of  pharyngeal  or  endotracheal 
tubes  when  conscious,  nor  breathe  quietly  in  the  subconscious  stage  of 
preliminary  anesthesia  the  irritating  vapors,  i.  e.,  30  to  45  per  cent  of 
ether  by  weight,  needed  for  establishment  of  complete  anesthesia.  These 
vapors  to  be  inhaled  quietly  must  be  inhaled  by  the  subconscious  patient 
in  such  a  way  as  to  arouse  no  unusual  impressions.  Attempting  to  blow 
vapors  of  the  strength  needed  for  the  induction  of  anesthesia  into  the 
pharynx  or  trachea  results  in  straining,  coughing,  gagging,  and  the 
swallowing  of  air.  Only  when  the  patient  is  completely  relaxed  can 
insufflation  methods  be  instituted.  This  period  of  face-mask  delivery 
occupies  six  to  twelve  minutes  for  the  most  advantageous  relaxation. 
If  the  operative  procedure  is  now  to  occupy  more  than  five  or  ten  min- 
utes, automatic  insufflation  may  be  established  with  decided  advantage. 

"Of  course,  it  is  to  be  distinctly  understood  that  in  the  administra- 
tion of  anesthetics  by  the  aid  or  means  of  automatic  contrivances  intelli- 
gent supervision  is  at  all  times  necessary." 

Connell  ^  compares  endotracheal  and  endopharyngeal  anesthesia  in 
the  following  manner : 

"The  ideal  place  to  deliver  ether  vapor  in  air  is,  without  question, 
directly  into  the  trachea  by  insufflation  through  a  loose  endotracheal 
catheter  after  .the  method  of  Meltzer.  For  effective  delivery,  for  com- 
plete and  certain  aeration,  for  even  and  controllable  anesthetization,  for 
freedom  from  shock  and  from  the  sequels  of  ether  anesthesia,  this 
method  is  not  surpassed. 

"Time  does  not  permit  me  to  elaborate  on  these  nor  on  the  various 
accessory  advantages  of  this  method,  namely:  the  ability  to  maintain, 
when  desired,  positive  pressure  on  the  interior  of  the  lung,  to  exclude 
mucous  and  other  foreign  material  from  the  bronchial  system,  and  to 
maintain  an  ideal  artificial  respiration  if  accident  arises. 

"The  one  and  only  hindrance  to  the  establishment  of  the  endo- 
tracheal delivery  as  a  routine  method  of  anesthesia  is  the  act  of  intuba- 
tion. 

^  Extracts  from  paper  read  by  invitation  before  the  first  annual  meeting  of 
the  American  Association  of  Anesthetists,  Minn.,  June  18,  1913. 


ETHER  239 

"This  alone,  with  its  possible  dangers,  its  ever-present  delays,  and 
occasional  difficulty  of  intubation  will,  no  doubt,  effectively  block  tin; 
general  adoption  of  this  very  useful  and  effective  mode  of  delivery  as 
a  routine  method  of  anesthesia/' 

Endopharyngeal  anesthesia  is  not  so  thoroughly  effective  in  control 
over  aeration  or  over  positive  pressure,  nor  so  effective  in  exclurling  for- 
eign material  from  the  larynx  as  the  endotracheal  delivery. 

Oxygen-Ether  Administration. — According  to  the  investigations  of 
some  authorities,  the  apparent  advantage  by  the  administration  of  oxy- 
gen is  in  the  exact  and  equal  dosage  at  all  times. 

Hewitt  states :  ^  "There  is  little  if  any  advantage  to  be  gained  by 
this  system  of  anesthetizing,  except  in  certain  special  cases.  We  have 
seen  that  in  vigorous  subjects  some  degree  of  air  limitation  is  actually 
advantageous  in  conducting  etherization.  When  we  pass,  however, 
from  the  vigorous  subject,  at  one  end  of  the  scale,  to  the  exhausted  and 
feeble  individual  at  the  other,  we  have  not  only  to  be  careful  to  provide 
a  sufficient  supply  of  air  with  the  anesthetic,  but  we  may  even  find  it 
necessary  to  replace  air  by  oxygen  in  our  administration.  Generally 
speaking,  when  respiratory  embarrassment  is  present  to  such  a  degree 
that  there  is  duskiness  or  actual  cyanosis,  ether  is,  as  we  have  seen, 
contraindicated.  In  certain  exceptional  and  desperate  cases,  however, 
in  which  defective  blood  oxygenation  coexists  with  such  a  degree  of 
cardiac  derangement  that  the  risk  in  giving  a  general  anesthetic  is  that 
sudden  syncope  may  arise  from  a  very  slight  degree  of  respiratory  em- 
barrassment, ether  may  be  the  only  permissible  anesthetic,  and  under 
such  exceptional  circumstances  as  these  the  administration  is  best  ef- 
fected in  conjunction  with  oxygen." 

Others  do  not  agree  with  Hewitt  that  little  or  no  advantage  is  to  be 
gained  by  the  administration  of  oxygen  with  ether.  On  the  other 
hand,  we  have  every  reason  to  believe  that  the  after-effects  of  ether  are 
considerably  diminished  by  the  combination  with  oxygen  instead  of 
air.  Sufficient  data  are  not  at  hand  for  us  to  speak  authoritatively  upon 
this  subject.  The  administration  of  oxygen  with  ether  is  one  of 
the  simplest  and  at  the  same  time  safest  procedures  possible.  At- 
tach any  vapor  inhaler  to  the  ordinary  large  hospital  oxygen  tank  and 
allow  the  oxygen  to  pass  through  the  ether,  and  this  vapor  to  then  pass 
through  the  water  bottle  and  thence  to  the  patient.  A  very  simple 
apparatus  for  the  administration  of  ether  and  oxygen  can  be  quickly 
made  as  follows : 

Procure  two  wash  bottles  holding  about  six  ounces.  Have  the  rub- 
ber stoppers  perforated  to  hold  small  glass  tubes,  as  in  the  ordinary 
wash  bottle  that  accompanies  any  oxygen  tank  iised  in  hospitals.  The 
first  bottle  should  be  filled  with  four  ounces  of  ether,  the  second  bottle 
'  Hewitt :     ' '  Anaesthetics, ' '  340. 


240 


ANESTHESIA 


with  four  ounces  of  water.  Allow  the  oxygen-ether  vapor  to  pass 
through  the  water  bottle  by  a  rubber  tube  connecting  the  two  bottles. 
The  efferent  tube  should  then  j)ass  on  to  the  patient.  This  vapor  may 
be  administered  through  the  apex  of  an  ordinary  cone,  the  cone  to  be 
made  more  or  less  air-tight  by  towels  wrung  out  in  hot  water  placed 

around  the  margin  of  the 
cone  and  on  tlie  patient's 
face.  We  again  refer  to  chart 
(page  668)  of  a  patient 
anesthetized  with  oxygen  and 
ether,  showing  the  even  pulse, 
temperature,  respiration,  and 
blood  pressure.  The  only  ob- 
jection to  the  impromptu  ap- 
paratus is  the  fact  that  the 
oxygen  or  ether  cannot  be  in- 
creased or  decreased  separate- 
ly, as  in  the  Gwathmey  or 
some  similar  apparatus  espe- 
cially made  for  that  purpose. 
When  using  this  method  the 
patient  should  be  anesthetized 
by  the  nitrous  oxid-ether  or 
oil  of  orange-ether  sequence 
or  the  chloroform-ether  se- 
quence, and  after  reaching 
the  surgical  stage  a  switch 
should  be  made  to  the  oxy- 
gen-ether combination.  The 
pulse  will  be  found  to  be 'full 
and  bounding,  the  respira- 
tions deep  and  regular,  and 
the  color  index  marked.  Suf- 
ficient air  will  be  let  in  by 
such  a  mask  to  slightly  dilute 
the  oxygen.  The  oxygen-ether  combination  has  not  been  tried  out  by 
the  closed  method  except  in  very  short  cases,  and  is  not  recommended. 
Few  complications  will  arise  to  give  the  anesthetist  uneasiness  when  the 
oxygen-ether  combination  is  administered  with  a  suitable  apparatus  and 
by  the  open  method,  already  described. 

Concentration  of  Ether   Vapor.^ — Dreser  has   made  laboratory  ex- 
periments regarding  the  percentages  of  respirable  ether  vapor.     Differ- 
ent accurate  mixtures,  placed  in  rubber  bags,  were  inhaled  by  a  number 
^  Johns  Hopkins  Hasp.  Bull.,  Jan.,  1895,  No.  6. 


Fig.    107. — Three-Bottle     Vapor     Apparatus 
Attached  to  Oxygen  Tank. 


ETHER 


241 


of  men.  All  agreed  that  8  jDer  cent  ether  vapor  was  irrespirable,  that 
9  per  cent  caused  contraction  of  the  glottis,  that  7  per  cent  caused  irri- 
tation and  coitgh,  that  6  per  cent  was  slightly  irritating  hut  not  irre- 
spirable, and  that  5  per  cent  was  usually  respirahle.  Dreser  concluded 
that:  "A  person  in  a  conscious  state  should  not  inhale  ether  vapor  ex- 
ceeding 7  per  cent.  Now  when  a  patient  by  inhaling  a  weaker  (concen- 
tration of  ether  vapor  has  been  made  insensible,  to  such  a  degree  at  least 
as  to  show  no  more  reflex-  action,  this  very  state  will  favor  the  injuri- 
ous effect  of  the  stronger  concentration  upon  the  lungs.     As  long  as  the 


ETHER        VAPOR       IN        AIR 

PRESSURE    760  Mm      TEMR  ?2*  C  HUMIDITY  ISSS  6Y  VOLUME. 

PRESSURE. 

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Fig.  IOS.^Chart  I,  Showing  the  Necessary  Percentage  of  Ether  Vapor  for  the 
Endophabyngeal  or  Endotracheal  Administration. 


patient  is  conscious,  the  reflex  contraction  of  the  glottis  prevents  the 
irrespirable  gas  or  vapors  from  entering  the  finest  air  passages."  The 
anesthetist  should  take  care  that  the  lungs  of  the  narcotized  patient 
are  not  injured.  In  a  closed  inhaler  the  percentage  of  carbonic  acid 
met  with  in  these  experiments,  even  with  healthy  persons,  was  never 
high  enough  to  produce  the  slightest  narcosis,  "therefore  the  percentage 
of  carbonic  acid  met  with  in  the  air  of  the  masks  could  not  be  looked 
upon  as  having  a  paralyzing  or  narcotizing  effect." 

Karl  Connell  ^  was  the  first  to  develop  the  accurate  percentages  of 
ether  necessary  for  surgical  anesthesia  when  given  by  the  vapor  method 
either  endopharyngeally  or  endotracheally.  These  charts  represent  a 
composite  of  three  hundred  cases  of  surgical  anesthesia  at  the  Eoose- 
velt  Hospital  charted  after  a  working  experience  had  been  gained  on  a 
previous,  series  of  about  six  hundred  cases. 

Chart  I  indicates  the  zones  of  ether  anesthesia  in  terms  of  weight 

^  Extracts  from  a  paper  read  by  invitation  before  the  first  annual  meeting 
of  the  American  Association  of  Anesthetists,  Minn.,  June  18,  1913. 


242 


ANESTHESIA 


of  ether  to  air  delivered  under  working  conditions.  The  volumetric 
equivalent  and  ether  vapor  pressure  equivalent  are  tabulated  in  parallel 
columns,  as  is  the  absolute  weight  of  ether  per  liter  in  the  air  at  de- 
livery and  at  body  temperature. 

These  zon-es  are  for  practical  working  guidance  in  surgical  etheriza- 
tion, and  are  not  absolute.  The  zones  above  the  15  per  cent  level  gradu- 
ally lower  toward  that  level  as  the  anesthetic  tension  of  about  48  milli- 


ZONCfr    OP    ANE.6TKv.IA 


PR.OPOUr-40 


euacoNscious 


^T      SuB  -CONS. 


COI<4Fu.filOM 


%IMCM.  PTiBL4TYPt 

—  •-AUCOHOklc     TYPL 


Fig.  109. — Chart  II,  Showing  the  Most  Advantageous  Ether  Pressure. 


meters  of  the  entire  body  is  attained.  At  the  end  of  an  hour  of  full 
anesthesia  even  the  zone  of  deep  anesthesia  for  a  considerable  length  of 
time  might  result  lethally.  For  example,  when  a  dog,  after  anesthetic 
saturation,  is  carried  in  the  zone  of  profound  anesthesia  by  endotracheal 
delivery,  respiratory  effort  ceases  in  about  an  hour,  only  to  begin  again 
when  the  ether  tension  is  lowered.  Such  dosage  would  result  fatally  if 
provision  is  not  made  for  artificial  respiration.  These  zones  are  the  same 
whether  the  delivery  be  by  face-mask  or  by  insufflation. 

Chart  II  shows  the  most  advantageous  ether  pressure  to  maintain 
in  the  pulmonary  air,  charted  in  terms  of  weight  of  ether  in  air  under 
usual  working  conditions  at  sea  level. 

The  percentages  above  15  per  cent  during  the  preliminary  and  early 
stage  of  full  surgical  anesthesia  are  needed  to  establish  the  proper 
anesthetic  tension  in  the  arterial  blood  to  the  sensorium  pending  such 


ETHER  243 

time  as  the  entire  circulating  and  fixed  tissues  oJ;  the  body  are  brought 
to  uniform  tension.  As  seen  on  the  chart,  there  is  a  difference  of  20 
to  30  minutes  between  the  length  of  time  such  saturation  takes  in 
a  man  of  the  young,  robust,  or  alcoholic  type  to  the  much  shorter  time 
taken  to  saturate  the  small,  relaxed  woman  or  child.  All  types,  how- 
ever, when  the  general  tension  is  once  established,  run  on  the  same 
base  line.  This,  for  complete  anesthesia,  is  between  14  per  cent  and  15 
per  cent  by  weight  of  ether,  yielding  a  tension  between  45  and  51  milli- 
meters. The  absolute  point  is  not  as  yet  fully  established,  but  is  proba- 
bly about  48  millimeters.  In  fact,  it  would  seem  from  preliminary  ob- 
servation that  this  tension  is  basic  not  alone  for  all  types  of  man,  but 
also  for  the  entire  animal  kingdom.  Below  this  level  the  operative 
case  may  be  carried  where  only  light  anesthesia  is  desired,  or  when  the 
operation  reaches  such  a  stage  that  protection  against  shock  influence 
is  no  longer  needed  (i.  e.,  that  very  effective  protection  conferred  by 
full  ether  anesthesia),  or  where  the  anesthetist  desires  the  patient  to 
enter  the  zone  of  slow  ether  desaturation  and  recovering  consciousness. 
This  recovery  zone  may  be  so  gauged  that  in  short  operations  the  patient 
leaves  the  table  practically  conscious  and,  even  after  long  operations,  in 
full  possession  of  all  pharyngeal  reflexes. 

Saturation  of  the  arterial  blood  and  sensorium  is  complete  in  the 
curve  shown,  to  the  extent  of  full  surgical  anesthesia,  in  about  two  min- 
utes for  each  liter  of  circulating  blood,  being  complete  in  medium- 
sized  children  in  six  minutes,  and  in  ^  the  adult  in  twelve  minutes. 
Operations,  even  major  procedures,  may  be  begun  before  full  relaxation 
is  established  or  at  the  peak  of  the  preliminary  curve,  say  at  the  end 
of  six  minutes  in  a  docile  adult.  Yet  where  it  is  desired  to  fully  pro- 
tect the  patient  against  shock-producing  and  inhibitory  influences,  it  is 
desirable  to  wait  for  full  surgical  relaxation,  i.  e.,  about  ten  to  twelve 
minutes. 

While  the  arterial  blood  to  the  sensorium  may  be  fully  charged  by 
high  percentages  within  ten  minutes,  yet  the  general  body  of  an  adult 
is  not  brought  to  full  tension,  approximating  48  millimeters,  by  the 
delivery  curve  shown,  for  from  forty  to  sixty  minutes.  Desaturation 
proceeds  even  more  slowly,  although  marked  changes  of  deadened  or 
awakened  sensibility  may  be  seen  within  three  minutes  by  increase  or 
decrease  of  ten  millimeters  of  ether  vapor  pressure  in  the  air  deliv- 
ered. This,  sensitiveness  is  more  pronounced  before  the  anesthetic  ten- 
sion of  the  entire  body  is  established.  Partial  recovery  is  more  rapid 
than  deepening  anesthesia  by  changes  of  equal  degree  before  saturation 
is  complete.  After  the  anesthetic  tension  is  established,  anesthesia  may 
be  more  rapidly  deepened  than  diminished,  an  observation  readily  ex- 
plicable on  physical  and  chemical  grounds. 

The  patient  may  be  carried  in  the  zone  of  profound  anesthesia  or 


244  ANESTHESIA 

deep,  medium,  or  light  anesthesia  at  will.  With  the  data  at  present  in 
hand,  the  most  advantageous  anesthetization  by  ether  can  be  plotted  in 
advance  for  the  type  of  individual  and  for  the  nature  and  stage  of  the 
operation,  and  maintained  after  the  initial  stage  entirely  automatically, 
and,  were  it,  desirable,  without  the  presence  of  any  anesthetist.  The 
ether  intoxication  may  be  reduced  to  a  small  factor  and  shock  influence 
effectively  blocked. 

Conclusions. — The  percentages  of  ether  needed  by  man  are  well 
established,  and  the  most  advantageous  anesthesia  may  be  plotted  in 
advance.    These  percentages  are  probably  basic  for  the  animal  kingdom. 


Fig.  110. — ^Administration  of  Warmed  Ether  Vapor  by  the  Closed  Method. 

A  curve  plotted  for  man  for  advantageous  etherization  rapidly  ascends 
in  the  preliminary  stage  to  30  to  45  per  cent  by  weight  of  ether  in  air, 
after  five  minutes  it  falls,  reaching  26  per  cent  by  the  tenth  minute, 
when  surgical  relaxation  is  well  established.  Through  the  next  half 
hour  it  scales  downward,  reaching  15  per  cent  in  30  or  40  minutes. 
It  runs  on  or  about  this  base  line  for  some  hours,  descending  when  the 
zone  of  recovery  is  desired  to  be  entered. 

The  Closed  Method.— When  the  closed  method  is  decided  upon,  any 
mask  and  bag  used  in  the  gas-ether  sequence  may  be  employed.  A 
rubber  tube  from  the  three-bottle  vapor  inhaler  in  this  instance  will 
be  attached  to  the  stopcock  of  the  bag.  The  expiratory  valve  will  be 
left  slightly  open  so  as  to  have  the  escape  of  a  small  amount  of  air  at 
all  times,  while  at  the  same  time  constant  rebreathing  is  maintained. 
The  inspiratory  valve  of  the  inhaler  should  be  out  of  commission.  Air 
should  be  constantly  forced  in,  and  the  bag  kept  about  nine-tenths 
full  so  that  no  effort  either  to  inhale  or  exhale  is  exacted  of  the  patient. 

With  vigorous  pumping  a  bead  of  1/8  to  i/4  of  an  inch  in  height 
will  be  maintained  in  the  ether  bottle.     Continuous  pumping  must  be 


ETHER 


245 


maintained  throughout  the  administration  of  the  anesthetic.  Toward  the 
close  of  the  anesthesia  tlie  tubes  from  the  pumping  apparatus  and  of  the 
mask  should  be  detached  from  the  three-bottle  vapor  inhaler  and  at- 
tached to  the  warming  apparatus,  and  the  patient's  lungs  thus  thoroughly 
aerated  before  the  mask  is  removed  from  the  face,  the  bag  to  be  tjo 
inflated  as  before.  This  should  be  done  from  five  to  ten  minutes  before 
the  completion  of  the  operation  so  that  by  the  time  the  operation  is 


Fig.  111.— Diagrammatic  Sketch  of  the  Nitrous  Oxid-Sther  Vapor  Sequence. 


finished  the  patient's  reflexes  will  all  be  present  and  he  will  be  practically 
from  under  the  influence  of  the  anesthetic. 

Amount  of  the  Anesthetic  "Used. — With  the  closed  vapor  method 
usually  two  (rarely  three)  ounces  of  ether  per  hour  are  required;  if  three 
ounces  are  used  the  first  hour,  one  ounce  will  suffice  the  second  hour. 
With  the  open  method,  three  to  four  ounces  of  ether  are  necessary  to 
maintain  complete  relaxation. 

Care  of  the  Apparatus. — All  the  ether  and  chloroform  remaining  in 
the  apparatus  should  be  thrown  away.  The  water  bottle  should  be 
emptied,  and  the  bottles  detached  from  the  apparatus  (this  last  pro- 
cedure in  order  to  save  the  rubber  washers).  The  mask  and  bag  should 
be  thrown  into  the  sterilizer  and  boiled  as  are  other  surgical  apparatuses, 
or  they  should  be  thoroughly  rinsed  in  carbolic  1-40  or  bichlorid  solu- 
tion and  then  rinsed  in  cold  water.  If  a  tube  or  moiith  gag  is  used, 
it  should  also  be  thoroughly  boiled  after  each  operation. 

Hints. — The  principal  care  of  the  anesthetist  with  any  vapor  appa- 


246  ANESTPIESIA 

ratus  is  to  see  that  there  is  no  leakage,  either  at  the  bottles  or  face- 
piece  or  bag,  also  that  no  kinks  occur  in  the  rubber  tubing  or  that  pres- 
sure is  not  made  on  the  tube  by  assistants  or  nurses. 

Advantages. — The  following  are  the  advantages  of  the  vapor  method : 

First:  The  small  amount  of  the  anesthetic  used,  two  to  four  drams 
for  a  thirty-minute  operation,  or  two  or  three  ounces  of  ether  per  hour. 

Second:     The  technique  is  easily  acquired. 

Third :    Objectionable  mucous  rale  is  usually  entirely  absent. 

Fourth:  In  over  ninety  per  cent  of  cases  there  are  no  unpleasant 
after-effects. 

Fifth :    A  continuous  plane  of  narcosis  is  easily  maintained. 

Sixth:  An  intermitting  narcosis  which  is  wrong  in  principle  is 
avoided. 

Seventh :  The  passage  back  and  forth  over  the  dangerous  vomiting 
center  is  usually  made  easily. 

Treatment  of  Accidents. — When  respiration  ceases  the  first  thing  to 
do  is  to  give  the  patient  a  quick,  hard  slap  upon  the  chest.  If  this  does 
not  start  the  respiration,  the  next  movement  is  to  place  the  hands  upon 
the  side  walls  of  the  chest  and  press  very  hard  several  times  in  succes- 
sion. If  the  patient  does  not  begin  to  breathe  immediately  the  follow- 
ing procedures  must  be  followed  and  in  much  quicker  time  than  it  takes 
to  give  the  directions : 

First:    Insert  a  mouth  gag  and  pull  the  tongue  well  forward. 

Second :  Lower  the  head,  and  while  this  is  being  done  pressure 
upon  the  side  walls  of  the  chest  must  be  continued.  As  soon  as  the 
patient  is  lowered  to  the  Trendelenburg  position,  grasp  the  arms  just 
above  the  elbows,  and  press  them  vigorously  to  the  sides  and  then  draw 
the  arms  backward  and  sideways  over  the  head,  at  the  end  of  this  move- 
ment making  considerable  traction.  Eepeat  this  movement  about  15 
times  to  the  minute.  At  the  same  time  have  an  assistant  dilate  the 
sphincter  ani.  Another  assistant  can  be  vigorously  massaging  the  pre- 
cordial region  while  artificial  respiration  is  being  kept  up.  If  there  are 
a  sufficient  number  of  nurses  or  assistants  standing  around,  bandages 
starting  at  the  feet  and  continued  to  the  thighs  with  the  idea  of  ex- 
pressing the  blood  in  the  extremities  to  the  body  is  sometimes  beneficial. 
If  these  procedures  do  not  give  some  definite  result  within  two  minutes, 
the  Lewis  pendulum  swing  should  be  attempted. 

If  respiratory  arrest  is  due  to  mucus  or  saliva,  the  anesthetic  must 
be  discontinued,  a  mouth  gag  inserted,  and  the  upper  air  passages 
swabbed  out  with  a  sponge  placed  upon  a  long  sponge  holder. 

If  the  fourth  stage  is  brought  on  by  hemorrhage  or  shock  from 
handling  important  nerves  or  blood  vessels,  and  the  respiration  is  still 
good  and  a  dilute  ether  vapor  has  been  given,  a  Trendelenburg  position 
with  bandaging  of  the  lower  limbs  and  intravenous  saline  infusion  will 


ETHER  247 

usually  rectify  this  condition.  If  the  fourth  stage  is  anticipated  from 
certain  events,  it  may  be  sometimes  prevented  by  a  hot  rectal  saline 
infusion.  It  is  not  unusual  where  the  patient  is  in  an  extreme  condi- 
tion to  start  a  hypodermoclysis  at  the  time  the  operation  is  commenced. 

According  to  American  statistics,  one  death  occurs  in  5,623  adminis- 
trations of  ether  by  the  drop  or  vapor  method.  This  means  that  death 
is  due  to  gross  carelessness  or  ignorance. 

In  extremely  rare  and  unusual  cases  of  status  lymphaticus,  in 
which  the  organs  may  be  diseased  and  anomalous,  such  as  a  very  small 
heart  with  a  large  aorta  and  enlargement  of  the  tongue,  it  is  quite  con- 
ceivable that  the  heart  may  be  paralyzed  before  the  respiration  ceases. 
When  paralysis  occurs  from  this  condition  it  is  usually  during  primary 
anesthesia.  If  the  anesthesia  is  continued  for  15  minutes  or  over, 
compensation  occurs  and  a  death  after  that  time  could  hardly  be  at- 
tributed to  this  cause. 


INDICATIONS   AND    CONTRAINDICATIONS    OF    ETHER 

Indications. — Hewitt  states  that  in  "healthy  and  moderately  healthy 
subjects  the  risk  connected  with  the  administration  of  ether  is  very 
slight,  the  reported  fatalities  having  almost  invariably  taken  place  in 
exhausted  or  markedly  diseased  individuals." 

The  senior  author  agrees  with  Hewitt  as  to  the  risk  connected  with 
the  administration  of  ether. 

With  the  modern  methods  of  administration,  and  with  the  combina- 
tions and  sequences  which  make  it  possible  to  adapt  the  anesthetic  to  the 
patient,  the  indications  for  ether  almost  parallel  the  indications  for 
operation,  except,  of  course,  for  very  short  surgical  interventions. 

Ethe.'  is  especially  indicated  to  continue  the  narcosis  in  operations 
about  the  mouth  or  nose,  such  as  excision  of  the  tongue  or  lower  jaw, 
where  there  is  considerable  shock. 

Ether  by  the  vapor  or  drop  method  is  indicated  for  adenoid  and 
tonsil  cases,  and  wherever  the  status  lymphaticus  is  suspected.  Wher- 
ever a  deep  anesthesia  is  desired,  ether  by  the  closed  method  is  indi- 
cated, as  for  amputations,  dislocations,  genito-urinary  operations,  lapa- 
rotomies, excision  of  the  breast,  amputation  of  the  cervix,  vaginal  and 
supravaginal  hysterectomy,  and  in  all  conditions  of  shock  and  collapse. 

Contraindications. — The  first  objection  to  any  method  of  adminis- 
tration of  ether  is  where  the  patient  has  suffered  intensely  from  a  pre- 
vious administration  of  this  drug,  and  expresses  a  decided  dislike  for 
the  odor  and  after-effects.  Such  idiosyncrasies  must  be  respected.  The 
senior  author  knows  of  one  death  caused  by  disregarding  this  rule.  The 
history  of  this  case  is  appended. 


248  ANESTHESIA 

Patient,  female,  aged  35  years.  Operation,  removal  of  ovarian 
tumor.  The  anesthetist  was  warned  not  to  use  ether,  as  nausea  and 
vomiting  of  an  exaggerated  type  had  followed  a  previous  administra- 
tion of  this  agent.  The  anesthesia  was  begun  with  chloroform,  but  as 
surgical  anesthesia  was  reached  pulse,  respiration,  and  color  seemed  to 
indicate  a  change.  A  few  drops  of  ether  were  placed  upon  the  mask 
to  stimulate  the  patient.  Almost  immediately  vomiting  ensued.  Upon 
deepening  the  anesthesia  vomiting  ceased,  and  a  smooth  narcosis  en- 
sued to  the  end  of  the  operation.  Ether  was  used  from  time  to  time 
as  needed.  As  the  patient  came  out  of  the  anesthetic  vomiting  started 
again,  and  continued,  with  intermissions,  for  forty-eight  hours.  The 
character  of  this  vomiting  was  so  violent  that  a  retention  stitch  was 
broken  and  a  small  piece  of  intestine  was  caught  in  the  wound.  When 
the  dressings  were  removed  the  tissues  along  the  line  of  incision  ap- 
peared tense  and  swollen.  Upon  reopening  the  wound,  the  gut  was 
found  to  be  gangrenous,  and  this  portion  was  removed  under  an  anes- 
thetic.   In  spite  of  good  nursing,  peritonitis  and  death  followed. 

Nitrous  oxid  and  oxygen  would  probably  have  saved  the  life  of  this 
patient. 

Kocher  ^  states  that  respiratory  disturbances  and  pathological 
changes  in  the  respiratory  organs,  with  dyspnea,  are  contraindications 
of  prime  importance.  Ether,  he  holds,  causes  more  suffering  and  more 
lasting  damage  to  the  respiratory  organs  than  can  be  attributed  to 
chloroform. 

In  lung  and  kidney  disease,  bronchitis,  phthisis,  dyspnea,  and  em- 
physema, and  in  ophthalmic  operations,  patients  do  better  with  some 
other  anesthetic  than  ether. 

In  aneurism  and  atheroma  ether  is  contraindicated.  It  is  also 
contraindicated  in  acute  attacks  of  asthma  or  bronchitis.  In  chronic 
bronchitis  or  asthma  ether  introduced  cautiously  and  given  by  modern 
methods  is  perfectly  safe.  In  any  condition  with  high  blood  pressure 
ether  is  contraindicated. 

Mortimer  ^  states  that  ether  should  not,  as  a  rule,  be  given  to  in- 
fants and  young  children,  in  whom  it  excites  much  mucous  secretion 
which  may  embarrass  breathing  or  lead  to  bronchitis. 

Elderly  people  do  not  usually  take  ether  well,  because  of  the  de- 
generate state  of  the  respiratory  and  circulatory  systems.  Heavy  smok- 
ers and  people  whose  mouths  and  throats  are  in  an  unhealthy  state, 
who  are  likely  to  cough  and  secrete  much  mucus  and  to  have  enlarge- 
ment of  the  tongue  and  upper  air  passages,  are  considered  by  Mortimer  ^ 
as  unfavorable  subjects  for  ether. 

^ ' '  Text-Book  of  Operative  Surgery, ' '  50. 
^ ' '  Anesthesia  and  Analgesia, ' '  55. 
^  Loc.   cit. 


ETHER  249 

Ether  is  contraindicated  if  an  actual  cautery,  a  lamp,  or  any  kind  of 
electrical  spark  is  to  be  employed. 

Most  writers  state  that  ether  is  contraindicated  in  operations  upon 
the  brain,  because  of  the  desirability  of  having  the  field  of  operation  as 
free  from  blood  as  possible.  Many  surgeons,  however,  prefer  the  drop, 
or  vapor,  method  of  ether  in  all  operations  upon  the  brain.  Similarly, 
exophthalmic  goiter  is  stated  as  contraindicated,  but  many  surgeons  pre- 
fer ether  by  the  open  method  for  this  operation. 


CHAPTER   VI 

ETHYL    CHLOEID 

Chemistry  :  Chemical  History ;  History  of  Its  Use  as  an  Anesthetic ; 
Uses;  Preparation;  Properties;  Storage  and  Containers;  Impurities 
Which  May  Develop  in  Ethyl  Chlorid ;  Detection  of  Impurities  in  Ethyl 
Chlorid. 

Physiology  :  Effects  upon  Eespiratory  System ;  Effects  upon  the 
Circulatory  System ;  Effects  upon  the  IsTervous  System ;  Effects  upon  the 
Muscular  System ;  Effects  upon  the  Glandular  System ;  Causes  of  Death 
under  Ethyl  Chlorid  Anesthesia;  Stages  of  Anesthesia;  Elimination; 
Af ter-Effects ;  Comparison  with  Other  Anesthetic  Agents. 

Indications  and  Contraindications. 

Administration:  Experimental  Data;  Methods  of  Administration; 
Open  Method;  Semi-closed  Method;  Closed  Method;  Combinations  and 
Sequences. 

Bibliography. 

CHEMISTRY 

Chemical  History. — Ethyl  chlorid  ("sweet  spirit  of  salt";  cetJiylum 
chloratum;  cether  chloratus;  cether  hydro chloricus  seu  muriaticus;  hydro- 
chloric ether;  chloro-ethane ;  monochlorethane ;  chlorcethyl ;  leichter 
salzather;  ether  chlorhydrique;  chelen  or  chelene;  kelen  or  kelene;  ano- 
djmone;  antidolorin;  ethylol;  loco-dolor,  etc.)  was  first  obtained  in  alco- 
holic solution  by  Basil  Valentine  (pseudo-).^     Sweet  spirit  of  salt  was 

^  He  described  its  preparation  thus  (DiederJiolung  des  grossen  Steins  der 
uralten  Weisen,  ed.  Petrseus,  p.  72 )  :  "  This  I  also  say  that  when  the  spirit 
of  common  salt  unites  with  spirit  of  wine,  and  Is  distilled  three  times,  it  be- 
comes sweet  and  loses  its  sharpness."  In  his  "Last  Testament"  (Basilius  Val- 
entinus,  ed.  Petrseus,  p.  786)  he  also  says:  "Take  of  good  spirit  of  salt  which 
has  been  well  dephlegmated  and  contains  no  watery  particles  one  part;  pour  to 
this  half  a  part  of  the  best  and  most  concentrated  spiritus  vini,  which  also  con- 
tains no  phlegma  or  vegetable  mercury. ' '  Valentinus  goes  on  to  state  that  this 
mixture  must  be  repeatedly  distilled,  and  then  "placed  in  a  well-closed  bottle  and 
allowed  to  stand  for  a  month  or  until  it  has  all  become  quite  sweet  and  has  lost 
its  acid  taste.  Thus  is  the  spiritus  salis  et  vini  prepared,  and  may  be  readily 
extracted. ' ' 

In   1739   Johann  Pott   demonstrated   that   sweet   spirit    of   salt   could   be   ob- 

250 


ETHYL    CHLORID  251 

well  known  to  the  later  chemists.  Glauber,  for  example,  referred  to  it  in 
1648. 

In  1749  ^  Ludollf  stated  that,  on  heating  ah^ohol  with  sulphuric  acid 
and  sodium  chlorid,  a  distillate  was  obtained  whi(;h,  when  treated 
with  lime,  yielded  an  ether,  but  he  endeavored  in  vain  to  obtain  a  sim- 
ilar compound  by  the  action  of  hydrogen  chlorid  (muriatic  gas)  on 
alcohol.  Baume  was  also  unsuccessful  in  this  direction,  but  Woulfe  ^ 
obtained  the  preparation  in  this  way,  and  it  was  afterwards  prepared 
and  sold  by  an  apothecary  in  Germany  under  the  name  of  "Basse's 
hydrochloric  ether''  (1801). 

History  of  Its  "Use  as  an  Anesthetic. — Flourens  ^  drew  attention  to 
the  anesthetic  properties  of  ethyl  chlorid  in  1847,  and  Heyf elder,  in 
the  following  year,  first  administered  the  vapor  for  surgical  purposes. 
■Unsatisfactory  symptoms  often  accompanied  its  administration  at  that 
time,  these  effects  being  attributed  to  imperfection  in  the  manufacture 
and  the  consequent  presence  of  impurities.  The  use  of  the  agent  as  a 
general  anesthetic  was  abandoned  until  1895,  since  which  time  it  has 
rapidly  gained  in  favor.  This  is  principally  attributable  to  the  improved 
methods  of  administration  and  to  an  increase  in  the  knowledge  of  its 
properties  and  physiological  action;  and  last,  but  not  least,  to  improve- 
ments in  its  manufacture. 

Ethyl  chlorid  may  be  regarded  as  ethyl  alcohol  (CHgCHgOH),  in 
which  the  OH  has  been  replaced  by  CI;  hence  the  formula  CH3CH2CI, 
which  was  established  by  Colin  and  Robiquet.* 

Alcoholic  muriatic  ether  is  a  solution  of  ethyl  chlorid  in  an  equal 
amount  of  alcohol  by  volume.  It  has  been  used  as  an  internal  stimulant 
in  doses  of  0.6  to  1.8  c.c. 

Uses. — So  far  ethyl  chlorid  has  not  been  used  technically,  although 
Palmer  °  called  attention  to  its  advantages  (and  disadvantages)  as  an 
industrial  refrigerating  agent.  In  medicine  it  is  used  for  (a)  general 
anesthesia  (by  inhalation)  ;  (b)  local  anesthesia  (by  external  applica- 
tion, in  effect,  refrigeration)  ;  (c)  diagnostic  and  therapeutic  purposes. 
Its  physiological  action  will  be  referred  to  later. 

Preparation. — As  noted,  ethyl  chlorid  may  be  regarded  as  ethyl 
alcohol  (C2H5OH)  in  which  the  hydroxyl  has  been  replaced  by  chlorin. 

tained  by  the  action  of  butter  of  arsenic  or  butter  of  antimony  (arsenic  or 
antimony  trichlorid)  on  spirit  of  wine,  and  other  chemists  found  that  other 
metallic  chlorids  might  be  employed  for  the  same  purpose.  Eouelle,  in  1759, 
found  that  ethyl  chlorid  results  from  the  action  of  sulphur  chlorid,  phosphorus 
pentachlorid,  aluminum  chlorid,  ferric  chlorid,  stannic  chlorid,  etc.,  on  alcohol. 

^  Die  in  der  Medicin  siegende  Chemie  .  .  .  ,  Erfurt,   1746-9. 

^Phil.  Trans.,  1767,  520. 

=*  Hewitt:     "  Anssthetics, "  1907,  11. 

*  Ann.  cJiim.  phys.  (2),  1,  343. 

^Eng.  Digest,  5,  262. 


252  ANESTHESIA 

Ethyl  alcohol  is  the  raw  product  from  which  it  is  usually  made,  although 
ethyl  chlorid  results  in  the  regulated  chlorination  of  ethane/  and  on 
treating  acetic  and  other  ethers  with  hydrogen  chlorid  by  the  action  of 
hydrochloric  acid  on  ether  in  sealed  tubes/  and  by  the  action  of  chlorin 
on  ethyl  iodid.  In  actual  practice  ethyl  alcohol  is  mixed  with  hydrogen 
chlorid,  which  acts  as  a  desiccating  agent  itself,^  or  dehydrating  agents, 
as  zinc  chlorid  *  or  phosphorus  pentoxid  °  are  added  to  remove  the 
water  produced.  If  these  agents  were  not  added  the  reversible  reaction 
would  reach  an  equilibrium.  This  equilibrium  may  be  avoided  by 
increase  of  pressure.*^ 

Impurities  from  Materials  Used. — If  pure  hydrogen  chlorid  be 
used  there  is  little  danger  of  impurities  being  introduced  from  that 
source.  The  quality  of  the  alcohol  used,  however,  is  very  important.  If 
denatured  alcohol,  especially  if  wood  alcohol  be  the  denaturant,  or  one 
of  the  denaturing  substances,  then  methyl  chlorid  will  likely  be  pro- 

^  Darling:     Ann.,  150,  216;  Schorlemmer :     Compt.  rend.,  58,  703. 

=*  Berthelot. 

^  Ethyl  chlorid  may  be  prepared  by  distilling  ethyl  alcohol  (5  parts),  sul- 
phuric acid  (2  parts),  and  sodium  chlorid  (12  parts)  together,  or  by  passing 
dry  hydrogen  chlorid  into  absolute  alcohol;  but  it  is  said  that  the  action  of 
hydrochloric  acid  upon  alcohol  gives  a  poor  yield  of  chlorid  unless  zinc  chlo- 
rid is  added  to  the  alcohol  before  passing  in  hydrochloric  acid  (Groves:  J.  Chem. 
Soc,  1874,  S7,  637).  Groves  found  that  when  hydrochloric  acid  gas  was  passed 
into  a  boiling  solution  of  zinc  chlorid  (2  parts)  in  95  per  cent  ethyl  alcohol 
(3  parts),  the  yield  was  nearly  theoretical.  He  purified  the  product  by  wash- 
ing with  water. 

*Kruger  [J.  prakt.  Chem.  (2)  14,  193]  recommended  that  a  mixture  of  one 
part  of  zinc  chlorid  in  82  parts  of  ethyl  alcohol  should  be  saturated  with  hydro- 
chloric acid  gas  in  the  cold,  and  then  heated  to  the  boiling  point.  Hydrochloric 
acid  gas  being  conducted  into  the  mixture  during  distillation,  as  the  process  is 
carried  out,  a  reflux  condenser  prevents  the  alcohol  vapor  from  coming  over,  and 
the  zinc  chlorid  is  said  to  act  by  abstracting  water  from  the  alcohol,  the  nascent 
ethylene  combining  with  hydrogen  chlorid  to  form  ethyl  chlorid,  according  to 
Schorlemmer  (/.  Chem.  Soc.,  1876,  308).  On  the  action  of  hydrochloric  acid 
on  alcohol,  alone  and  in  the  presence  of  zinc  chlorid,  see  also  Robiquet  and 
Colin:  Ann.  chim.  phys.  (2),  1,  343;  Regnault,  ibid.  (2)  71,  355;  Kuhlmann: 
Ann.,  S3,  108;  and  Lowig,  Pogg.:  Ann.,  45,  346.  On  velocity  of  the  reaction, 
see  Kailan:  Monatsh.,  1907,  28,  559.  The  formation  of  ethyl  chlorid  in  this 
process  is  partly  due  to  the  action  of  hydrogen  chlorid  upon  alcohol,  and  partly 
to  the  union  of  this  nascent  ethylene  with  hydrogen  chlorid. 

°  The  practice  of  some  American  manufacturers  is  to  use  phosphorus  pen- 
toxid as  the  dehydrating  agent. 

*  The  process  of  Mennet  and  Cartier  (French  Patent,  206,  574,  June  23, 
1890)  relates  to  the  production  of  ethyl  chlorid.  An  autoclave  of  150  liters 
capacity  as  used,  into  which  a  mixture  of  95  kg.  of  hydrochloric  acid  (21°  Be.) 
and  34  kg.  of  93-95  per  cent  ethyl  alcohol  is  maintained  at  50  atmospheres 
pressure  and  at  130°  C.  for  about  28  hours.  The  pressure  is  then  diminished  to 
42  atmospheres,  and  finally  the  autoclave  is  cooled.  See  also  Hager's  Handhuch 
d.  pharm.  Praxis,  1910,  1,  189. 


ETHYL    CHLORID  253 

duced.  This  gas  (b.p.,  — 24°  C),  while  very  soluble  in  ethyl  cfilorid, 
may  easily  be  removed  by  rectification.  Aldehyds  form  compounds 
with  hydrogen  chlorid.  Any  acetic  acid  present  is  liable  to  form  acetyl 
chlorid,  and  the  higher  alcohols,  as  propyl,  butyl  and  amyl,  produce 
their  corresponding  halogen  derivatives.  It  is  desirable,  therefore,  to  use 
only  absolute  alcohol  of  the  highest  degree  of  rectification. 

An  examination  of  seven  different  makes  of  ethyl  chlorid  obtainable 
in  London  in  1905  showed  that  all  the  branded  samples  were  pure,  as 
was  also  one  unbranded  sample.  The  report  of  this  investigation  ^ 
states  that  ethyl  chlorid  should  be  free  from  water,  foreign  chlorids, 
acids,  aldehyds,  ether,  alcohol,  and  organo-metallic  substances. 

Purification. — Ethyl  chlorid  is  purified  -  by  passing  the  vapor 
through  water,  dilute  caustic  solution,  and  then  concentrated  sulphuric 
acid.  This  treatment  is  intended  to  free  it  from  alcohol,^  hydrogen 
chlorid,*  and  water.  Redistillation  is  sometimes  practiced.  This  rec- 
tification serves  to  remove  other  alkyl  chlorids,  the  methyl  going  off  in 
the  first  fractions  of  the  distillate,  and  the  higher  compounds  remain- 
ing in  the  residue. 

Properties. — Ethyl  chlorid  is  a  colorless  mobile  liquid  at  low  tem- 
peratures and  is  exceedingly  volatile.  It  possesses  a  sweetish  taste  and  a 
pungent,  yet  fragrant,  "ethereal"  odor.  It  is  inflammable,  burning, 
when  ignited,  with  a  smoky  green-edged  flame,  producing  fumes  of 
hydrogen  chlorid;  hence  care  must  be  exercised  in  using  it  near  an 
open  flame  or  a  hot  cautery.  It  even  decomposes  when  very  close  to  a 
hot  bulb  or  an  incandescent  electric  light. 

Ethyl  chlorid  does  not  freeze  at  — 29°  C;  it  possesses  a  boiling 
point  of  +12.5°  C.^;  and  its  specific  gravity  is  0.92138  at  0°  %  0.9176 
at  +8°  \  0.9510  at  +12°  «,  and  at  +25°  ^  the  vapor  has  a  specific 
gi'avity  of  0.91708.    Its  vapor  density  is  2.22. 

Water  dissolves  about  one-fiftieth  of  its  weight  of  ethyl  chlorid  and 
acquires  a  sweetish,  ethereal  taste.  Ethyl  chlorid  is  readily  soluble  in 
ethyl  alcohol  and  ethyl  ether,  and  neither  solution  should  give  a  reaction 
with  silver  nitrate  solution,  as  ethyl  chlorid  itself  does  not  react  with 
silver  nitrate  at  ordinary  temperatures.  Ethyl  chlorid  dissolves  phos- 
phorus, sulphur,  fats,  oils,  and  many  resins.     It  combines  with  many 

"■Lancet,  1905,   ii,   1631. 
'Pharm.  J.   (4),  15,  694. 

"Acetyl  chlorid  decomposes  to  acetic  and  hydrochloric  acids  with  water. 
*  And  other  bodies  forming  acids  with  water. 
=  Regnault:     Jahresber.,  1863,  67. 

"Pierre:      Coiwpt.    rend.,    27,    213.      Darling    {Jahresber.,    21,    328)    found   a 
density  of  0.9252  at  this  temperature. 
^Linnemann:      Ann.,   160,   195. 
'  Ramsay :     J.  Chem.  Soc.,  35,  470. 
'Perkin:     J.  prakt.  Chem.   (2),  31,  481. 


254 


ANESTHESIA 


metallic  chlorids — for  example,  antimony  pentachlorid  and  ferric  chlorid 
— to  form  crystalline  compounds. 

Storage    and    Containers. — Owing   to   its    extreme    volatility,    ethyl 
chlorid. cannot  be  kept  in  ordinary  bottles,  excej^t  at  a  temperature  be- 


FiG.  112. — Sealed  Tubes  of  Ethyl  Chlorid.     These  contain  3  and  5  c.c.  for  use  in 
various  inhalers  for  general  anesthesia. 


*i,->.'-\^'--.v^ 


Fig.  113. — Double-End  Ethyl  Chlorid  Tube.  This  possesses  the  advantage  of 
enabling  the  operator  to  utilize  the  spray  whose  emerging  angle  will  be  most  conven- 
ient.    They  are  put  up  in  10  and  30  gm  sizes. 


Fig.  114. — Automatic  Closing  Tube  for  Ethyl  Chlorid.  These  are  made  to  hold 
10,  30,  and  60  gm  of  ethyl  chlorid  and  are  used  for  local  and  general  anesthesia. 
They  may  be  graduated.  The  tube  is  glass,  but  the  automatic  cap  is  made  of  a  non- 
corroding  metal. 


Fig.  115. — Automatic  Closing  Tube  for  Ethyl  Chlorid.     It  is  graduated  in  cubic 
centimeters  for  discharging  any  desired  amount  and  containing  60  c.c. 


Fig.  116. — Flexible  Spraying  Nozzle.  This  is  detachable,  made  of  soft  German  silver 
tubing,  and  enables  the  operator  to  reach  any  tooth  and  to  enter  the  nose,  throat  or 
external  auditory  canal  to  apply  ethyl  chlorid  as  a  local  anesthetic. 

low  -+-10°  C,  and  even  then  the  stopper  must  be  tight-fitting  and  very 
well  secured,  and  the  bottles  should  preferably  be  stored  in  an  inverted 
position.  Ethyl  chlorid  is  now  supplied  on  the  market  in  sealed  or 
mechanically  capped  glass  or  metal  tubes  of  convenient  forms,  wherein 
the  ethyl  chlorid  is  held  under  pressure.     Automatic  closing  tubes  are 


ETHYL    CHLORID 


255 


preferable  for  local  anesthesia,  and  there  are  at  least  five  different  types 
of  these  on  the  American  market,  each  manufacturer  using  his  special 
form  of  container,  some  of  which  arc  described  here.  Ethyl  chlorid  is 
also  furnished  by  certain  manufacturers  in  plain  capped  tubes. 

Containers  of  ethyl  chlorid  should  be  kept  in  a  dark,  cool  place,  re- 
mote from  lights  or  fire;  and  no  empty  tiibes  should  be  refilled  with  a 


nBi.JI,jHi,'J,    J"     -,ll«liU»!l.|!!!!l!!»lll!IIIW-%u' 

50  p.c. 


Fig.  117. — Ferguson's  Ethyl  Chlorid  Tubes  for  General  and  Local  Anesthesia. 

A. — 50  c.c.  tube  of  ethyl  chlorid  intended  for  general  anesthesia  only.  The  capillary 
is  gauged  so  as  to  deliver  the  proper  amount  of  ethyl  chlorid  in  the  right  time  to  produce 
a  satisfactory  narcosis.  It  is  graduated  and  has  a  large  capillary  bore.  It  is  not  adapted 
for  producing  local  anesthesia. 

B. — 50  c.c.  tube  open,  showing  the  graduations. 

C. — Tubes  containing  respectively  30  c.c.  or  60  c.c.  of  ethyl  chlorid  are  made  for 
local  anesthesia  only.  The  capillary  on  each  is  of  the  same  size,  and  is  gauged  so  as 
to  deliver  the  minimum  amount  of  ethyl  chlorid  compatible  with  a  good  local  anesthesia, 
thereby  preventing  waste.  These  tubes  differ  from  the  50  c.c.  tube  in  capacity  and 
size  of  capillary  bore,  and  are  not  adapted  for  producing  general  anesthesia  except  in 
the  case  of  infants  or  young  children,  and  very  susceptible  subjects. 

Open  the  tube  by  pushing  the  thumb  button  forward  as  far  as  it  will  go  in  a  direction 
parallel  with  the  long  axis  of  the  tube.  Do  not  press  down  on  the  button,  as  by  doing 
so  the  capillary  tube  may  be  broken.  When  through  using,  remove  the  thumb  from 
the  button  and  allow  the  spring  to  bring  the  cap  back  in  place;  the  tube  is  thus  closed 
instantaneously  and  tightly.  If  any  foreign  matter  becomes  lodged  on  the  end  of  the 
capillary  tube,  interfering  with  its  free  working,  gently  wipe  it  off  with  the  finger,  at 
the  same  time  grasping  the  tube  in  the  hand  to  cause  pressure  by  body  heat  and  to  drive 
the  obstructing  particles  out.     Never  try  to  free  it  with  a  needle,  pin  or  other  instrument. 

fresh  lot  of  the  compound,  since  such  an  economy  may  result  in  spread- 
ing infection. 

Glass  as  Compared  ivith  Metal  Containers. — It  is  maintained  by  some 
that  ethyl  chlorid  decomposes  when  exposed  to  air  and  sunlight;  hence 
that  the  drug  should  be  kept  in  metal  containers.  It  is  further  claimed 
that,  inasmuch  as  ethyl  chlorid  is  inflammable,  there  is  less  danger  of 
breaking  in  accidentally  dropping  the  metal  container.  In  opposition  to 
this,  it  may  be  said  that,  in  filling  any  container,  no  air  remains  in  it  on 
account  of  the  great  volatility  of  ethyl  chlorid.  Furthermore,  in  draw- 
ing off  a'  portion  of  the  contents  of  a  tube,  pressure  is  produced  within 
the  tube  which  is  constant  for  each  temperature,  it  matters  not  how 
much  liquid  ethyl  chlorid  is  present,  so  long  as  there  is  some  liquid 


256 


ANESTHESIA 


there ;  hence  no  backward  pressure  is  created,  whereby  air  may  be  sucked 
into  the  tube.    Undoubtedly  light  facilitates  the  decomposition  of  ethyl 


Fia.  118. — The  Gebauer  Container  for  Ethyl  Chlorid. 

chlorid  by  oxygen,  but  it  has  not  been  shown  that  light  produces  any 
change  in  ethyl  chlorid  when  oxygen  is  absent.  Assuming  that  the 
ethyl  chlorid  is  pure,  there  is  another  objection  to  the  use  of  a  metal 


Fig.  119. — Technic  of  Ethyl  Chlorid  Measure-Dropper.  Attach  the  measure-drop- 
per to  an  ethyl  chlorid  tube;  holding  the  tube  in  a  horizontal  position  with  the  apex  of 
the  dropper  pointing  down,  open  the  valve  in  the  tube  by  gradually  turning  the  screw 
to  the  right,  allowing  the  ethyl  chlorid  to  fill  the  chamber  in  the  dropper,  at  the 
same  time  holding  the  thumb  over  the  opening  in  the  apex  of  the  dropper  as  shown  in 
cut.  When  the  graduated  chamber  in  the  dropper  is  filled  to  the  desired  amount, 
close  valve  again. 

Now  hold  the  tube  with  the  apex  of  the  dropper  pointing  downward  about  two  or  three 
inches  directly  above  the  gauze  in  the  inhaler  and  remove  the  thumb.  The  ethyl 
chlorid  will  now  issue  from  the  dropper  in  forms  of  drops,  which  are  directed  upon  the 
gauze  in  the  inhaler.  As  a  general  rule  3  to  5  c.c.  will  suffice  to  anesthetize  a  person 
for  a  short  operation,  but  there  is  no  fixed  rule  as  to  the  quantity  of  ethyl  chlorid  required, 
since  some  will  take  more  than  others.  The  anesthetist  must  be  guided  entirely  by  the 
symptoms  of  his  patient  as  to  the  duration  and  quantity  of  the  ethyl  chlorid  required. 
If  it  is  observed  that  3  c.c.  will  not  suffice  to  anesthetize  the  patient,  one  simply  opens 
the  valve  again  in  the  tube  and  lets  1  or  2  c.c.  more  of  ethyl  chlorid  flow  into  the  gradu- 
ated chamber  of  the  dropper  and  proceeds  as  before.  If  the  ethyl  chlorid  does  not 
drop  fast  enough  from  the  apex  of  the  dropper,  it  can  be  made  to  drop  faster  by  placing 
the  thumb  or  finger  over  the  opening  in  the  neck  of  the  dropper  marked  "A".  With  a 
little  practice  the  dropping  may  be  regulated. 


container,  namely,  inability  to  tell  how  much  of  the  preparation  is  within 
the  tube  and  how  much  has  been  or  is  being  used  in  the  anesthesia.  This 
has  been  met  by  having  a  graduated  (3  c.c.  capacity)  dropper  made  of 
glass,  which  may  be  attached  to  the  metal  container.  The  design  of  such 
a  dropper  is  shown  in  Figure  119. 


ETHYL    CHLORID  257 

Impurities  Which  May  Develop  in  Ethyl  Chlorid. — Uncertain  re- 
sults have  been  encountered  by  several  vi^ho  have  used  ethyl  chlorid  for 
general  anesthesia  and  these  have  been  attributed  in  some  cases  to  im- 
purities that  were  present  and  were  later  detected  chemically.^ 

The  original  product  must  not  have  been  properly  purified,  for  the 
conditions  essential  for  the  decomposition  of  ethyl  chlorid  itself  in- 
volve oxygen,  and,  as  animadverted,  oxygen  has  no  opportunity  to  enter 
the  receptacle  in  which  ethyl  chlorid  is  dispensed.  The  presence  of  small 
amounts  of  water  may  bring  about  a  reverse  change  in  ethyl  chlorid, 
with  the  formation  of  ethyl  alcohol  and  hydrogen  chlorid.  The  latter 
may  readily  be  detected  by  spraying  some  of  the  drug  into  a  clear  silver 
nitrate  solution.  The  appearance  of  a  turbidity  indicates  free  hydrogen 
chlorid,  as  pure  ethyl  chlorid  does  not  thus  react  with  silver  nitrate. 

Detection  of  Impurities  in  Ethyl  Chlorid. — The  impurities  likely  to 
occur  in  ethyl  chlorid  are  (a)  those  which  it  brings  with  it  from  the 
manufacturer  and  (b)  those  resulting  through  careless  storage.  While 
the  exact  nature  of  all  of  these  is  unknown,  yet  ethyl  chlorid,  complying 
with  the  requirements  of  the  pharmacopoeias  as  given  below,  is  entirely 
suitable  for  the  purjDoses  for  which  it  is  intended.  On  account  of  its 
volatility,  the  examination  of  ethyl  chlorid  presents  more  difficulties 
than  are  encountered  in  the  cases  of  ethyl  ether  and  chloroform;  and  it 
is  indeed  fortunate  that  it  may  be  easily  prepared  in  a  state  of  com- 
parative chemical  purity. 

The  Pharmaeopceia  of  the  United  States  ^  prescribes  the  following 
tests  for  purity : 

1.  "If  10  c.c.  of  ethyl  chlorid,  while  cold,  be  dissolved  in  alcohol, 
and  a  few  drops  of  silver  nitrate  T.  S.  be  added,  no  turbidity  should  be 
produced  (absence  of  liydrocldoric  acid). 

2.  "If  10  c.c.  of  ethyl  chlorid  be  agitated  with  10  c.c.  of  cold  water 
and  the  supernatant  stratum  of  ethyl  chlorid  be  evaporated  spontane- 
ously, and  if  a  few  drops  of  potassium  dichromate  T.  S.  be  added  to  the 
remaining  aqueous  liquid,  followed  by  some  diluted  sulphuric  acid,  and 
the  mixture  be  boiled,  no  odor  of  aldehyd  should  be  developed,  and  a 
greenish  or  purplish  color  should  not  be  produced  in  the  liquid  {absence 
of  alcohol). 

3.  "On  allowing  ethyl  chlorid  to  evaporate  from  clean,  odorless 
blotting  paper,  which  has  been  saturated  with  it,  no  unpleasant  odor 
should  remain  upon  the  paper   (absence  of  sulphur  compounds,  etc.)." 

The  British  Pharmacopaiia  requires  that  it  should  leave  no  residue  on 
evaporation  and  that  an  aqueous  or  alcohol  extract  should  have  no  acid 
reaction  with  blue  litmus  paper.     The  Deutsches  Arzneibuch  ^  requires 

^Hawley:     J.  Am.  Med.  Assn.,  1906,  47,  502. 
^  8th  decennial  revision,  32. 
2 1910,  37. 


258  ANESTHESIA 

also  that  "during  evaporation,  and,  thereafter,  no  garlic  odor  should  be 
apparent  (phosphorus  compounds)."  The  French  Codex,  ^  while  giving 
the  incorrect  specific  gravity,  states  it  should  be  free  from  ethyl  bromid 
and  iodid.  The  Pharmacopoeia  Helvetica  ^  requires  that,  when  its  vapors 
are  led  through  water,  the  water  must  not  give  an  acid  reaction  with 
litmus  nor  a  reaction  with  silver  nitrate. 
All  the  tests  seek  to  eliminate  acids. 


PHYSIOLOGY 

One  of  us  (J.  T.  G.)  has  not  employed  ethyl  chlorid,  either  in  the 
laboratory  or  in  the  operating  room,  to  such  an  extent  as  to  warrant  the 
consideration  of  this  agent  from  the  point  of  view  of  personal  experience. 
In  the  pages  which  follow,  therefore,  the  reported  work  of  other  investi- 
gators is  freely  and  almost  exclusively  utilized. 

Effects  Upon  the  Respiratory  System. — The  effect  of  ethyl  chlorid 
upon  the  lungs,  according  to  Miiller,^  is  pathological  rather  than  physio- 
logical. Cole  *  found  that,  when  given  in  the  form  commercially  known 
as  somnoform  (see  p.  818),  ethyl  chlorid  markedly  increased  the  size 
and  rate  of  contraction  and  the  tone  of  the  diaphragm,  which  remained 
in  a  state  of  strong  tonic  contraction,  the  heart  still  beating  strongly. 

Embley  ^  found,  from  his  experiments  upon  animals,  that,  as  the 
blood  pressure  fell,  respiration  ceased,  and,  as  the  blood  pressure  rose, 
the  respiration  returned.  He  does  not,  therefore,  agree  with  other  in- 
vestigators in  the  view  that  respiration  may  be  paralyzed  by  ethyl 
chlorid  independently  of  fall  of  blood  pressure,  in  ordinary  administra- 

»1908,  249. 

=*  1907,  27. 

^Miiller,  B.:      "  Narkologie, "  1,  454. 

*Cole:     Proc.  Physiol.  Soc,  June  lb,  1903;  J.  Physiol,  29,  25. 

^Embley:  Proc.  Roy.  Soc,  78,  31  (1906);  Pharm.  J.  (4),  24,  650;  Lancet, 
April  20,  1907.  The  solubility  of  ethyl  chlorid  vapor  in  water  at  normal  pres- 
sure and  +21°  C.  is  253.36  per  cent  by  volume  (0.678  per  cent  by  weight)  ;  and 
the  solubility  in  blood  is  approximately  500  per  cent  of  vapor  by  volume  at  38°  C. 
The  heart  muscle  is  paralyzed  by  ethyl  chlorid  just  as  it  is  by  chloroform  and 
in  contrast  with  ethyl  ether,  but  the  quantity  of  ethyl  chlorid  vapor  in  air 
required  is  nineteen  times  as  great  as  that  of  chloroform  to  produce  similar 
results.  On  the  vascular  system  the  net  result  is  dilatation,  but  the  degree  of 
paralysis  is  strikingly  less  than  that  produced  by  chloroform,  even  when  the 
latter  is  present  in  less  than  one-tenth  of  the  quantity  of  air  inspired.  A 
strength  of  5  to  7  per  cent  of  ethyl  chlorid  vapor  in  the  air  required  appears 
to  be  the  limit  of  safety  from  danger  of  syncope  in  dogs  for  prolonged  and 
continuous  administration,  and  the  conclusions  arrived  at  by  Embley  are  con- 
sidered to  apply  to  man.  For  the  administration  of  ethyl  chlorid  he  advises 
employing  a  gasometer  containing  the  proper  mixture  of  air  and  ethyl  chlorid 
vapor. 


ETHYL    CHLORID  259 

tions.  Eespiratory  arrest  is  preceded  by  a  remarkable  prolongation  of 
the  respiratory  pause.  In  none  of  Embley's  experiments  was  the  heart 
arrested  before  respiration.  The  integrity  of  the  respiratory  mechanism 
in  ethyl  chlorid  narcosis,  he  holds,  is  dependent  upon  the  maintenance 
of  blood  pressure. 

Eespiratory  frequency  is  not  affected  as  a  rule ;  but  McCardie  ^  states 
that  ethyl  chlorid  quickens  and  deepens  respiration. 

Effects  Upon  the  Circulatory  System. — According  to  Miiller,"  the 
solubility  of  ethyl  chlorid  in  water  is  slight  and  the  solution  very  loose, 
for  which  reasons  the  blood-serum  takes  up  only  a  slight  amount.  It  is 
not  much  more  soluble  in  blood-serum  than  in  pure  water.  A  small 
amount  is,  however,  taken  up  by  the  blood  corpuscles.  On  account  of  its 
slight  solubility  in  blood-serum,  very  highly  concentrated  mixtures  of 
air  and  ethyl  chlorid  must  be  carried  to  the  lungs,  for,  in  consequence 
of  the  loose  solution,  the  vapor  is  at  once  given  off  from  the  blood,  the 
patient  awakening  promptly  unless  such  highly  concentrated  mixtures 
are  administered. 

Embley,^  who  investigated  the  pharmacology  of  ethyl  chlorid,  found 
that  the  solubility  of  the  vapor  in  water  at  normal  pressure  and  21°  C. 
is  253°,  36  per  cent  by  volume  (0.G78  per  cent  by  weight)  ;  and  the  solu- 
bility in  blood  is  approximately  500  per  cent  of  vapor  by  volume  at 
38°  C. 

Camus  and  Nicloux  *  found  that  ethyl  chlorid  is  taken  up  by  the 
blood  with  great  rapidity,  and  that  it  is  also  eliminated  very  rapidly. 

All  authorities  are  agreed  that  in  full  surgical  narcosis  with  ethyl 
chlorid  a  very  great  fall  in  blood  pressure  is  noted.  Even  when  given 
for  a  short  time,  according  to  McCardie,*^  a  fall  of  blood  pressure  takes 
place. 

Embley  ^  says :  "The  effect  of  ethyl  chlorid  upon  the  heart  muscle, 
as  is  the  case  with  chloroform,  is  paralytic,  but  the  quantity  of  ethyl 
chlorid  vapor  required  in  the  air  is  nineteen  times  as  great  as  that  of 
chloroform  to  produce  comparable  results."  He  further  states  that  the 
effect  of  ethyl  chlorid  upon  the  arterioles  isolated  from  the  central  ner- 
vous system  is  relaxation.  (In  this  respect  also  it  is  similar  to  chloro- 
form, but  the  amount  required  is  vastly  greater.)  The  effects  upon  the 
vasomotor  mechanism  also  are  parallel  with  the  action  of  chloroform. 
From  his  experimental  work  Embley  found  that  the  action  of  ethyl 

^  McCardie :      ' '  The   Position    of    and    Mortality    from    Ethyl   Chloride    as    a 
General  Anesthetic,"  Brit.  Med.  J.,  March  17,  1906,  616. 

^  Miiller :     Loc.  cit. 

*  Embley:     Proc.  Boy.  Soc,  78,  31  (1906)  ;  Lancet,  April  20,  1907;  Pliarm.  J., 
24,  650. 

*  Camus  and  Nicloux:     Compt.  rend.,  145,  1437. 

"McCardie:     Lancet,  Oct.  7,  1905;   Brit.  Med.  J.,  March  17,  1906. 

*  Embley :     Loc.  cit. 


260  ANESTHESIA 

chlorid  on  the  vascular  system  caused  dilatation.  The  degree  of  paraly- 
sis, however,  is  strikingly  less  than  that  produced  by  chloroform,  "even 
when  the  latter  is  present  in  less  than  1/10  of  the  quantity  of  the  air 
inspired.'^ 

Embley  concludes:  (1)  That  vagus  inhibition  of  the  heart  occurs 
very  readily  in  ethyl  chlorid  vapor  of  a  strength  of  ten  per  cent  and 
upward  when  administered  in  the  air  inspired;  (2)  that  sudden  fall  of 
blood  pressure  occurred  during  the  administration  of  ethyl  chlorid  vapor 
in  a  strength  ranging  from  ten  to  twenty  per  cent,  owing  to  vagus  in- 
hibition of  the  heart.  If  thirty  per  cent  is  administered,  fall  of  blood 
pressure  is  due  to  weakening  of  the  cardiac  arterial  musculature;  (3) 
that  cardiac  inhibition  is  not  so  serious  from  ethyl  chlorid  as  it  is  from 
chloroform.  It  requires  nineteen  times  more  ethyl  chlorid  to  produce 
a  given  degree  of  cardiac  depression  than  is  required  of  chloroform, 
while  it  requires  only  four  times  as  much  to  produce  cardiac  arrest  by 
vagus  stimulation;  hence,  inhibition  sets  in  relatively  more  rapidly. 
Herein  rests  the  relative  safety  of  ethyl  chlorid. 

Webster,^  who  experimented  upon  animals  with  ethyl  chlorid,  ethyl 
bromid,  and  ethyl  iodid,  says:  "The  difference  of  any  action  between 
the  chlorid,  bromid,  iodid  and  somnoform  is  one  of  degree  only  and 
this  degree  seems  to  depend  upon  the  volatility  of  the  drugs."  With 
small  doses  he  found  that  there  was  a  slight  rise  in  blood  pressure,  fol- 
lowed by  a  return  to  normal,  whereas,  with  larger  doses,  the  pressure 
rapidly  fell. 

Buxton  ^  states  that  flushing  of  the  face,  due  to  dilatation  of  the 
peripheral  vessels,  is  always  associated  with  ethyl  chlorid  inhalation, 
and  may  account,  in  part,  for  any  fall  of  blood  pressure  that  takes 
place.  When  large  doses  of  ethyl  chlorid  are  employed  the  circulatory 
changes  are  secondary  to  the  respiratory  changes. 

Eifects  "Upon  the  Nervous  System. — Mliller  holds  that  the  blood  car- 
ries the  gas  into  the  cerebrum  and  to  the  ganglion  cells,  into  the  fluids 
of  which  the  ethyl  chlorid  passes,  and  is  taken  up  by  the  cholesterin- 
lecithin  mixtures.  This  results  in  paralysis  of  the  cells.  But,  as  the 
solubility  in  the  cell-juice  is  slight,  only  a  small  amount  of  ethyl  chlorid 
enters  into  the  cell,  insufficient,  in  short  narcosis,  to  paralyze  all  the 
cells.  Although  the  centers  of  pain-sensation  may  be  paralyzed,  the 
quantities  do  not  always  suffice  to  paralyze  the  more  resistant  centers 
against  narcotic  agents ;  as  a  result,  the  reflexes,  the  muscles,  and  so  forth 
are  not  completely  paralyzed,  inhibited,  or  relaxed  in  the  anesthesia.  It 
is  only  after  the  ethyl  chlorid  vapors  have  been  inhaled  for  some  time 
that  larger  amounts  of  these  vapors  collect  in  the  central  elements  of  the 
ganglion-cells,  in  the  cholesterin-lecithin  mixtures  (which  dissolve  larger 

^Webster:     Bio-Chem.  J.,  1,  328    (1906). 
2  Buxton:     "Anaesthetics,"  256. 


ETHYL    CHLORID  261 

quantities  of  ethyl  chlorid  than  water  or  blood-scrum),  inducing  a  total 
paralysis  of  the  centers. 

The  action  upon  the  nerve  tissue  was  studied  by  Cantelupc,  who 
found  that  ethyl  chlorid  exerted  a  double  action;  on  tlie  one  hand  a 
direct  chemical  action,  and  on  the  other  an  indirect  action,  due  to  cere- 
bral anemia  through  paralysis  of  the  vasomotor  center.  The  fibers  of 
the  white  substance,  in  the  cerebrum  as  well  as  the  cerebellum,  are  found 
to  present  slight  degenerative  changes,  which  are  interpreted  as  the  ex- 
pression of  the  nutritive  changes  of  the  nerve-cell,  and  therefore  also  of 
its  nervous  process,  and  which  still  persist  at  the  period  of  awakening. 
Such  changes  may  be  purely  functional,  and  therefore  curable. 

Effects  "Upon  the  Muscular  System. — Muscular  rigidity  may  be  pres- 
ent during  the  stage  of  excitement.  In  some  cases,  according  to  Hewitt,^ 
muscular  relaxation  accompanies  stertor,  but  there  is  more  often  some 
rigidity.  This  rigidity  in  some  subjects  may  be  so  general  as  to  cul- 
minate in  opisthotonos.  The  strong  tendency  to  contraction  of  the 
masseter  muscles  has  been  noted  by  all  administrators  of  this  ethyl 
chlorid. 

Effects  Upon  the  Glandular  System. — It  is  held  by  various  observers 
that  the  gastric  and  intestinal  functions  are  slightly  influenced ;  the  secre- 
tions of  the  liver  and  the  kidneys  are  diminished. 

Causes  of  Death  Tinder  Ethyl  Chlorid  Anesthesia. — From  the  fore- 
going discussion  of  the  effects  of  ethyl  chlorid  upon  the  organism  we 
may  agree  with  the  statement  of  Hewitt  ^  that  ethyl  chlorid  may  prove 
fatal  in  two  distinct  ways,  viz.:  (1)  by  simple  overdose,  ethyl  chlorid 
toxemia,  or  ethyl  chlorid  syncope;  (2)  by  intercurrent  respiratory  em- 
harrassment  (asphyxia). 

The  prominent  features  of  simple  overdose,  as  noted  by  Hewitt,  are : 
pallor,  pulselessness,  arrest  of  breathing,  wide  dilatation  of  the  pupils, 
general  muscular  flaccidity  and  separation  of  the  lids.  Cardiac  arrest 
quickly  follows. 

In  death  from  asphyxia  with  ethyl  chlorid  the  intercurrent  respira- 
tory embarrassment,  according  to  Hewitt,  may  depress  a  circulation  al- 
ready depressed  by  the  agent.  The  prominent  features  in  this  instance 
are:  spasm  about  the  jaws,  mouth,  tongue,  larynx,  or  respiratory  mus- 
cles. Eespiratory  arrest,  with  some  cyanosis,  supervenes,  followed  by 
cardiac  arrest. 

(For  the  mortality  of  ethyl  chlorid,  see  Appendix  on  Statistics.) 
Stages  of  Anesthesia. — The  stages  of  ethyl  chlorid  anesthesia  are  a 
little  different  from  those  of  the  other  pulmonary  anesthetics. 

The  first  stage  is  an  analgesic  stage  which  commences  after  two  or 
three  breaths  of  the  anesthetic,  and  which  lasts  over  thirty  seconds. 

^Hewitt:     "Anaesthetics,"  439. 

UUd.,  455. 


262  ANESTHESIA 

This  is  the  stage  before  stertor  and  other  signs  of  anesthesia  appear.  It 
is  sufficient  for  opening  an  abscess,  but  the  operator  is  taking  the  risk  of 
causing  pain  unless  he  works  rapidly. 

The  second  stage  is  a  true  anesthetic  stage  which  lasts  from  one  to 
three  minutes  after  removing  the  mask  from  the  face.  In  fact,  the 
anesthetic  stage  is  sometimes  deepened  after  the  removal  of  the  mask, 
owing  to  the  absorption  of  the  ethyl  chlorid  from  the  lower  air  passages. 
On  account  of  the  spasm  of  the  masseter,  as  frequently  happens  during 
this  stage,  it  is  necessary  that  a  dental  prop  be  inserted  between  the 
teeth  in  all  cases,  and  not  only  when  intra-oral  operation  is  contem- 
plated. ^ 

The  third  stage  is  again  one  of  analgesia.  It  lasts  from  30  to  40 
seconds,  during  which  no  sensation  is  felt,  but  the  patient  may  talk  or 
move  slightly.  Just  before  the  patient  becomes  conscious,  swallowing 
occurs  for  some  little  time.  The  first  sense  to  return  is  hearing,  and 
the  next  is  sight. 

The  fourth  stage,  when  the  administration  is  continued  too  far, 
corresponds  to  that  of  other  inhalation  anesthetics  under  the  same  cir- 
cumstances, viz.,  the  bulb  is  affected,  causing  cessation  of  respiration, 
arrest  of  the  heart,  and  death. 

In  prolonged  ethyl  chlorid  narcosis,  Miiller  distinguishes  four  stages, 
as  in  all  narcoses.  The  first  and  second  stages  are  very  brief.  The  re- 
flexes, however,  are  lost,  and  the  pupils  present  exactly  the  same  be- 
havior as  in  other  narcoses.  In  the  brief  narcosis,  on  the  other  hand, 
the  pupils  continue  to  react,  nor  are  the  other  reflexes  lost. 

Herrenknecht,^  whose  experience  with  ethyl  chlorid  as  a  narcotic 
agent  was  so  entirely  satisfactory  that  he  earnestly  endorsed  its  employ- 
ment, distinguished  four  stages  of  narcosis,  as  follows :  ( 1 )  The  pre- 
narcotic  analgesic  stage;  (2)  the  stage  of  excitement;  (3)  the  stage  of 
deep  sleep;  (4)  the  post-narcotic  analgesic  stage. 

The  first  stage,  according  to  Herrenknecht,  is  chiefly  characterized 
by  the  diminishing  frequency  of  the  pulse  and  respiration,  the  deepen- 
ing of  the  respiration  and  the  onset  of  moderate  muscular  tension.  The 
eyeballs  are  almost  invariably  turned  upward.  The  patient  is  still  con- 
scious, however,  and  aware  of  the  fact  that  he  is  being  operated  upon, 
although  there  is  not  the  least  sensation  of  pain.  The  hearing  is  still 
completely  preserved  in  this  stage. 

The  second  stage,  or  stage  of  excitement,  occurred  only  rarely  in  the 
experience  of  Herrenknecht,  and  was  limited  to  habitual  abusers  of  al- 
cohol and  to  very  nervous  and  excitable  patients.  As  a  prophylactic 
measure,    he    always    administered    morphin,    or    preferably    morphin- 

^  Boyle:     "Practical  Anesthetics,"  126. 

"  Herrenknecht :  ' '  3000  Aethylchloridnarkosen, ' '  Miinch.  med.  Woch.,  1907, 
No.  49,  2421. 


ETHYL    CHLORID  263 

scopolamin,  to  patients  of  this  type,  prior  to  the  narcosis;  and  more 
ethyl  chloric!  was  injected  into  the  mask,  in  order  to  hasten  the  third 
stage. 

The  third  stage  is  characterized  by  muscular  relaxation,  and  com- 
plete loss  of  reaction  to  external  stimuli;  the  conjunctival  and  corneal 
reflexes  have  disappeared ;  the  patient  appears  as  if  quietly  asleep. 

The  fourth  stage  resembles  the  first,  except  that  the  patient  con- 
veys the  impression  of  being  wide  awake;  there  is  no  noteworthy  pain. 
The  fourth  stage  is  hardly  ever  absent,  not  even  when  the  third  stage 
has  not  been  reached  and  the  supply  of  ethyl  chlorid  has  been  stopped, 
after  the  onset  of  the  first  stage.  The  end  of  the  fourth  stage  is  recog- 
nized by  the  movements  of  defense  on  the  part  of  the  patient,  and  the 
manifestation  of  pain  on  operative  interference. 

The  signs  of  complete  anesthesia  under  ethyl  chlorid  are:  (1)  A 
quick,  deep,  and  regular  respiration;  (2)  eyeballs  fixed  or  rolling;  (3) 
face  usually  slightly  flushed;  (4)  muscular  relaxation  or  rigidity;  (5) 
pupils  widely  dilated;  (6)  absence  of  conjunctival  and  corneal  reflexes. 

A  continuous,  safe  narcosis  is  not  easily  maintained  with  the  present 
methods.  Much  cyanosis  is  a  signal  for  the  admission  of  air  or  the 
temporary  discontinuance  of  the  anesthetic.  Eespiratory  embarrassment 
and  spasm  of  the  jaw  are  common  in  muscular  subjects.  Increasing 
stertor  is  a  signal  for  more  air. 

The  best  guide  is  probably  the  respiration.  If  the  anesthesia  is  very 
deep,  cessation  of  the  administration  is  indicated.  It  is  to  be  borne  in 
mind  that  anesthesia  is  deepened  after  the  administration  is  discon- 
tinued, owing  to  the  absorption  of  the  agent  from  the  lower  air-passages. 
The  pitlse  is  usually  slow. 

The  signs  of  an  overdose  are:  (1)  Unusually  widely  dilated  and 
fixed  pupils;  (2)  very  great  pallor;  (3)  intermittent  respirations  or 
gasping  for  breath. 

Elimination. — Experiments  were  performed  by  Lotheissen,^  to  deter- 
mine if  ethyl  chlorid  was  still  demonstrable  in  the  expired  air  some 
time  after  the  narcosis.  For  this  purpose,  the  expired  air  was  passed 
through  a  pure  concentrated  alcoholic  solution  of  potassium  hydroxid 
into  water,  which  was  then  heated  and  mixed  with  a  solution  of  silver 
nitrate,  in  order  to  test  for  the  presence  of  chlorin.  The  reaction  never 
occurred  when  the  inspired  ethyl  chlorid  was  expired  through  this  appa- 
ratus; whereas  it  appeared  at  once  after  the  direct  introduction  of  even 
small  traces  of  ethyl  chlorid  vapor.  Upon  the  basis  of  these  observa- 
tions, Lotheissen  concluded  that  ethyl  chlorid  was  not  breathed  out 
again  in  the  undecomposed  state,  the  chlorin,  at  least,  disappearing 
from  the  expired  air.     But  as  this  air  did  not  possess  the  odor  of  mus- 

^ Lotheissen:  " Aethylchlorid  Sauerstoff  Narkose,"  Arch,  TcUn.  Chir.,  1910, 
91,  65. 


264  ANESTHESIA 

tard-oil,  Lotheissen  was  of  the  opinion  that  a  chemical  change  occurred; 
perhaps  the  formation  of  ethyl  thiocarbimide  (C3H5NS),  for  the  lungs 
have  a  strong  reducing  power.  At  any  rate,  the  ethyl  chlorid  does  not 
remain  fixed  for  any  length  of  time,  so  that  it  cannot  exert  a  prolonged 
narcotizing  effect,  which  means  a  great  advantage  in  case  of  threatened 
asphyxia. 

The  excretion  of  ethyl  chlorid  ^  takes  place  mostly  through  the 
lungs;  especially  in  brief  narcosis  nearly  all  the  vapors  are  again  elimi- 
nated by  the  lungs  relatively  rapidly  on  account  of  the  looseness  of  the 
solution  in  the  blood.  The  kidneys  and  other  glands  enter  only  very 
slightly  into  consideration  in  brief  narcosis,  essential  amounts  of  ethyl 
chlorid  being  eliminated  by  those  organs  only  in  prolonged  narcosis. 
The  very  slight  solubility  in  the  blood-serum  also  induces  the  complete 
absence  of  gastric  affections,  nausea,  vomiting,  etc.,  after  brief  narcosis, 
for  the  small  quantities  in  the  blood  are  at  once  eliminated  and  do  not 
pass  into  the  gastric  juice,  or  do  so  only  in  very  minute  amounts,  devoid 
of  any  effect.  In  prolonged  narcoses,  larger  amounts  enter  the  blood  and 
are  also  secreted  into  the  gastric  juice,  giving  rise  to  nausea  or  even 
vomiting  after  awakening.  The  solubility  in  the  cholesterin-lecithin 
mixtures,  which  are  formed  in  the  protoplasm  of  the  cells,  is  also  less 
than  with  chloroform  or  ether,  for  example,  so  that  no  such  quantities 
can  accumulate  in  the  cells.  When  the  inhalation  of  new  vapors  in  the 
narcosis  ceases,  no  new  quantities  are  taken  to  the  cells,  but  the  quanti- 
ties contained  in  the  cells  are  reeliminated.  However,  this  elimination 
can  take  place  only  in  the  quantities  which  the  blood-serum  is  capable  of 
dissolving.  As  the  cholesterin-lecithin  mixtures  of  the  ganglion  cells 
dissolve  ethyl  chlorid,  and  therefore  accumulate  the  same  during  the 
narcosis,  in  considerably  larger  quantity  than  the  blood-serum  is  capable 
of  dissolving,  the  narcosis  will  naturally  continue  until  the  last  quanti- 
ties of  ethyl  chlorid  have  been  eliminated  from  the  ganglion  cells.  In 
a  brief  narcosis,  these  accumulated  quantities  are  very  trifling  in 
amount;  after  a  prolonged  anesthesia,  however,  they  reach  a  certain 
amount  beyond  which  one  must  not  pass  or  the  patient  will  die.  As 
ethyl  chlorid  is  only  slightly  soluble  in  cholesterin-lecithin  mixtures — 
less  than  chloroform,  for  example — this  quantity  is  smaller  than  what  is 
stored  up  in  the  ganglion  cells.  Nevertheless,  after  prolonged  narcosis, 
this  quantity  of  ethyl  chlorid  will  suffice  to  produce  after-effects,  in  the 
form  of  vertigo,  headache,  etc. 

After-Effects. — Concerning  the  after-effects  of  ethyl  chlorid  upon 
the  animal  organism,  Konig  -  states  that  the  result  of  the  examination  of 
the  urine  of  the  animals  for  albumin  proved  negative  in  all  his  experi- 
ments.   Examinations  were  made  a  few  hours  after  the  narcosis,  and  on 

^  Miiller :     Loc.  cit. 

''Konig,   E.:      "Die    Chloraethylnarkose/ '    Arch.    Min.    Chir.    1912,    99,    147. 


ETHYL    CHLORID  265 

the  next  day.  This  serves  to  show  that  the  ethyl  chh)rifl  exerts  no  in- 
jurious action  upon  the  blood  corpuscles  and  the  kidneys,  leaving  no 
noteworthy  after-effects  in  this  respect. 

The  after-effects  occurred  in  so  far,  however,  as  all  the  animals  were 
found  to  undergo  a  more  or  less  considerable  loss  of  body  weight,  usually 
about  100  gm.,  within  8  to  10  days.  Several  animals  suffered  from  diar- 
rhea. Eabbits  which  were  narcotized  repeatedly,  on  successive  days,  or 
every  other  day,  recovered  very  slowly  from  the  narcosis;  they  were  ex- 
tremely drowsy  and  weak,  a  considerable  time  elapsing  before  the  normal 
condition  was  reestablished.  This  observation,  as  well  as  the  loss  in 
body  weight,  combined  with  severe  diarrhea,  permits  the  conclusion  that 
ethyl  chlorid  hardly  leaves  the  organism  so  rapidly  as  is  generally  as- 
sumed to  be  the  case.  Perhaps  there  occurs  a  chemical  change,  namely, 
a  decomposition  of  the  ethyl  chlorid  in  the  lung,  which  organ  is  said  to 
possess  a  strong  reducing  power.  It  is  probable  that  this  was  suggested 
by  Lotheissen,  who  asserted  after  his  experiments  that  at  least  the 
chlorin  must  disappear  from  the  expired  air,  as  it  is  no  longer  de- 
monstrable in  the  same.  Konig  points  out  that  Lotheissen's  experiments 
and  conclusions  are  not  tenable,  and  that  these  investigations  in  no  way 
prove  a  retention  of  chlorin  in  the  organism. 

Clinically,  the  after-effects  vary  according  to  the  preparation  of  the 
patient,  the  length  of  the  administration,  and  the  method  employed.  It 
is  conceded  by  all  unbiassed  observers  that  vomiting  is  one  of  the  com- 
monest after-effects,  occurring  in  from  15  to  20  per  cent  of  cases.  Nau- 
sea associated  with  headache  occurs  in  even  a  greater  percentage.  The 
nausea  is  the  same  as  in  ether  narcosis,  but  of  shorter  duration.  It 
seldom  lasts  over  15  minutes;  in  exceptional  cases,  however,  it  has  lasted 
30  hours. ^  Hysterical  symptoms  may  appear  in  young  girls  and  erotic 
patients.  Erotic  thoughts  and  dreams  may  occur  with  this  anesthetic  as 
with  nitrous  oxid  and  oxygen.  {It  is  for  this  reason  that  the  anesthetic 
should  never  be  administered  except  in  the  presence  of  a  third  person.) 

Fainting  and  collapse  are  sometimes  observed.  Jaundice  has  been  re- 
ported in  a  few  cases,  showing  the  effect  upon  the  liver.  Albuminuria  is 
absent  except  in  prolonged  cases.  Fatty  degeneration  of  the  kidneys  and 
liver  has  been  noted  after  repeated  administrations.  These  symptoms 
may  come  on  in  from  one  to  six  hours  after  the  administration  and 
may  continue  for  several  hours.  Collapse  is  more  liable  to  follow  ethyl 
chlorid  than  any  other  anesthetic."  This  is  the  principal  reason  why 
attempts  have  never  been  made  at  a  prolonged  anesthesia  with  this  drug. 
Symptoms  of  asphyxia  appear  only  with  too  highly  concentrated  vapors, 
or  when  the  inhalation  is  continued  after  the  onset  of  prolonged  slum- 
ber; i.  e.,  when  the  so-called  narJcosenbreite  (extent  of  narcosis)  is  ex- 
ceeded. 

^Hewitt:     Loc.  cit.,  446.  ^  Ibid. 


266  ANESTHESIA 

Comparison  with  Other  Anesthetic  Agents.- — The  narcotic  power  of 
ethyl  chlorid,  when  administered  by  inhalation,  mixed  with  air,  is  simi- 
lar to  that  of  ether,  and  weaker  than  that  of  chloroform.  Because  of 
the  rapidity  with  which  it  abolishes  consciousness,  and  the  evanescent 
effects  (fugaciousness)  of  the  agent,  unless  these  are  forestalled,  it  is 
more  comparable  to  nitrous  oxid  than  to  either  chloroform  or  ether. 

Maass,^  who  is  an  opponent  of  ethyl  chlorid  narcosis,  maintains  that, 
in  regard  to  its  absolute  danger,  ethyl  chlorid  should  be  ranked  as  at 
least  equal  to  chloroform,  for  like  the  latter  it  may  cause  heart-death. 
Eelatively,  ethyl  chlorid  is  more  dangerous  than  chloroform,  in  so  far 
as  its  desirable  as  well  as  undesirable  effects  are  characterized  by  the 
rapidity  of  the  onset  and  the  almost  instantaneous  development  to  a 
climax;  while  the  risk  of  a  fatal  overdosage  is  rendered  imminent  by  the 
smallness  of  the  permissible  dose,  as  well  as  the  impossibility  of  working 
in  great  dilution  with  air.  For  this  reason,  the  successive  use  of  ethyl 
chlorid  and  chloroform  is  by  no  means  advisable,  as  the  prepared  or 
suggested  injury  through  the  brief  ethyl  chlorid  anesthesia  will  develop 
to  such  an  extent  in  the  following  chloroform-narcosis,  by  the  summa- 
tion of  the  stimuli,  as  it  were,  as  to  endanger  the  patient's  life  to  an 
alarming  degree,  especially  as  the  disturbances  concerned  in  the  summa- 
tion all  affect  the  circulatory  system.  In  a  similar  way,  Maass  also 
considers  the  beginning  of  ether  narcosis  with  ethyl  chlorid  as  an  added 
danger.  Ethyl  chlorid  cannot  even  remotely  concur  with  nitrous  oxid, 
where  the  effect  of  the  latter  suffices,  for  this  gas  is  very  much  less  dan- 
gerous than  ethyl  chlorid.  It  is  better  to  employ  ether,  he  holds,  when 
nitrous  oxid  or  local  anesthesia  is  not  sufficient.  The  respiration  and 
the  heart  action  are  apt  to  be  overwhelmed  very  suddenly,  the  ethyl 
chlorid  attacking  the  body  so  vehemently  that  it  succumbs  before  the 
system  can  accommodate  itself  to  its  action. 

Ethyl  chlorid  is  appropriate  for  use  in  the  act  of  parturition,  be- 
cause the  patient's  exhaustion  permits  the  production  of  a  relaxed  state 
approaching  analgesia  with  small  doses  of  an  anesthetic  sufficient  for  the 
application  of  forceps.  Another  special  indication  for  ethyl  chlorid  is 
in  war  surgery,  because  soldiers  who  have  been  anesthetized  with  ethyl 
chlorid  awaken  sooner  and  more  completely,  and  thus  become  fit  for 
transportation,  than  those  who  have  received  ether  or  chloroform. 
Furthermore,  ethyl  chlorid  involves  less  danger  of  shock  than  chloro- 
form, for  wounded  soldiers  suffering  from  both  physical  and  mental  ex- 
haustion. 

The  advantages  of  ethyl  chlorid  as  compared  with  other  liquid  in- 
halation, or  aliphatic  anesthetics,  consist  in  the  rapidity  with  which  it 
produces  anesthesia,  and  the  usually  complete  absence  of  after-effects, 

^  Maass :  * '  Chloraethyl  als  Inhalationsanaesthetikum, ' '  Therap.  Monatsh,, 
1907,  303. 


ETHYL    CHLORID  267 

when  properly  employed.  On  the  other  hand,  ethyl  chlorid  can  in  no 
way  replace  either  chloroform  or  ether,  where  prolonged  loss  of  sensa- 
tion is  required,  its  great  toxicity  strictly  forbidding  the  exceeding  of  a 
maximum  dose  of  5  c.c. 

Upon  the  basis  of  his  experience,  Herrenknecht  ^  concludes  that  ethyl 
chlorid  is  the  least  dangerous  narcotic  which  we  possess  at  present,  not 
even  excepting  nitrous  oxid.  However,  it  is  not  applicable  for  prolonged 
narcoses,  because  the  scope  of  the  narcosis  is  evidently  not  a  wide  one 
in  the  case  of  ethyl  chlorid,  and  is  therefore  easily  surpassed.  It  is 
naturally  dangerous  when  too  much  is  given  in  a  short  time  of  such  a 
highly  efficient  agent,  capable  of  so  rapidly  inducing  narcosis.  The  in- 
halation should  be  interrupted  with  the  onset  of  muscular  relaxation  and 
disappearance  of  reflexes.  According  to  animal  experiments,  and  the  ex- 
perience of  other  observers  with  patients,  respiration  usually  stops  first 
with  ethyl  chlorid,  followed  by  failure  of  the  heart  action.  Hence,  im- 
mediate artificial  respiration,  perhaps  combined  with  cardiac  massage, 
will  probably  always  prevent  a  threatened  death,  as  the  very  volatile  com- 
pound promptly  escapes  from  the  body.  In  spite  of  the  large  number  of 
his  ethyl  chlorid  narcoses  (3,000)  Herrenknecht  has  never  yet  been 
obliged  to  resort  to  artificial  respiration  or  stimulation  with  camphor. 

Hewitt  ^  thinks  that  ethyl  chlorid  is  far  more  dangerous  than  nitrous 
oxid  and  distinctly  more  dangerous  than  ether,  the  reason  for  this  being 
stated  as  the  considerable  fall  of  blood  pressure  which  takes  place.  Re- 
garding its  safety,  Boyle  ^  says  ethyl  chlorid  cannot  be  compared  with 
nitrous  oxid  and  oxygen,  and  rates  its  dangers  as  equal  to  those  of  chloro- 
form. Luke  and  Ross  *  state  that  this  drug  is  safer  as  an  anesthetic 
agent  than  ether,  chloroform,  or  ethyl  bromid,  but  that  it  must  not  be 
considered  as  safe  as  nitrous  oxid. 

Behr  ^  indicates,  as  special  advantages  of  ethyl  chlorid,  the  relative 
harmlessness  of  the  drug  when  used  in  suitable  doses,  its  pleasant  odor, 
which  facilitates  its  employment,  more  especially  for  children,  also  the 
absence  of  a  feeling  of  suffocation  and  the  diminution  of  the  stage  of 
excitement,  the  rapid  induction  of  anesthesia,  the  speedy  return  to  con- 
sciousness, and,  finally,  the  total  absence  of  after-effects. 

INDICATIONS    AND    CONTRAINDICATIONS 

Indications. — In  this  discussion  of  the  indications  for  the  use  of 
ethyl  chlorid  no  reference  will  be  made  to  the  administration  of  this 

*  Herrenknecht :     Loc.  cit. 
'^  Hewitt:      "Anaesthetics,"  1907,  135,  444. 
'Boyle:     ''Practical  Anaesthetics,"  1907,  141. 
'Luke   and   Ross:       'Anaesthesia  in  Dental  Surgery." 
Behr:      Berl.  klin.  Woch.,  1911,  No.  2,  67. 


268  ANESTHESIA 

agent  as  a  preliminary  to  ether  or  chloroform,  this  phase  of  the  subject 
being  considered  under  each  respective  combination  or  sequence. 

Children,  according  to  all  the  writers  consulted  in  this  connection, 
are  the -best  subjects  for  the  administration  of  ethyl  chlorid.  It  has 
been  used  as  a  routine  anesthetic  for  children  five  days  old  and  up- 
ward/ being  especially  well  borne  by  infants  from  a  few  weeks  to  a  few 
months  old.  Children  of  any  age,  up  to  about  eight  years,  take  this 
anesthetic,  as  a  rule,  without  difficulty,  losing  consciousness  and  becom- 
ing quiet  in  about  ten  seconds,  and  giving  a  satisfactory  anesthesia  of  a 
minute  or  a  minute  and  a  half.  It  is  preferred  by  some  ^  to  any  other 
agent  for  circumcisions,  for  example,  and  for  the  majority  of  short 
operations  in  children  under  eight  years  of  age.^  In  dental  operations 
upon  children,  where  not  more  than  two  teeth  are  to  be  extracted,  and 
for  removal  of  tonsils  and  adenoids,  it  is  advocated.* 

Luke  and  Ross,^  Cantlie,^  Mortimer,'^  and  many  others,  consider  ethyl 
chlorid  preferable  to  nitrous  oxid  for  short  operations  upon  very  young 
subjects. 

Adults  present  no  special  indications  for  ethyl  chlorid  anesthesia. 
This  agent  may  be  given  satisfactorily,  however,  to  very  aged  and  anemic 
subjects,^  but  great  care  is  advocated  °  in  such  cases,  the  recumbent  posi- 
tion being  insisted  upon.  In  patients  whose  general  condition  is  satisfac- 
tory, and  when  the  administration  is  skilfully  conducted,  ethyl  chlorid 
may  safely  be  employed." 

For  short  operations,  where  greater  muscular  relaxation  is  required 
than  is  obtainable  by  nitrous  oxid,  or  where  a  deeper  narcosis  is  desired, 
for  short  examinations  or  operations  in  gynecological  work,  and  in  brief 
operations  in  obstetrical  practice,  ethyl  chlorid  may  be  satisfactorily 
employed.  ^^ 

Contraindications. — The  earlier  advocates  of  ethyl  chlorid  acknowl- 
edged practically  no  contraindications  to  its  use.  Girard,  for  example, 
according  to  McCardie,^^  held  that  circulatory  troubles  and  respiratory 
affections  did  not  contraindicate  its  use ;  neither  age  nor  sex,  nor  alcohol- 

^  Mortimer:     "Anesthesia  and  Analgesia,"  50. 

-Knight,  H.  Astley:  "Notes  on  Ethyl  Chloride,"  Brit.  Med.  J.,  March  17, 
1906,  618. 

^McCardie:     Loc.  cii. 

*  Cantlie,   James :     ' '  Anesthetics  and  Surgical  Technique. ' ' 

=  Luke  and  Eoss:     "Anesthesia  in  Dental  Surgery,"  92. 

''Cantlie:     Loc.  cit.,  171. 

'Mortimer:     Log.  cit.,  50. 

'Luke  and  Eoss:     Loc.  cit.,  92. 

"  Buxton. 

"Hewitt:     Loc.  cit.,  441   (1907). 

"McCardie:     Brit.  Med.  J.,  March  17,  1906,  617. 

^^  Ibid. 


ETHYL    CHLORID  269 

ism,  nor  other  intoxications  forbade  its  administration.  The  only  doubt- 
ful factor  was  the  state  of  the  urinary  organs. 

In  a  general  way  it  may  bo  stated  that  robust,  athletic,  and  alcoholic 
subjects  and  confirmed  smokers  present  contraindications  to  the  use  of 
ethyl  chlorid,  as  do  likewise  persons  suffering  from  chronic  or  acute 
diseases.  Any  obstruction  to  swallowing  renders  ethyl  chlorid  danger- 
ous. Respiratory  affections,  whether  due  to  contracted  or  small  air 
passages,  to  marked  pharyngeal  catarrh,  or  to  diseases  of  the  lungs  in- 
volving marked  respiratory  embarrassment,  particularly  in  the  presence 
of  bronchorrhea,  are  contraindications  to  the  administration  of  this 
agent.  Feeble  heart  action,  with  a  probability  of  fatty  degeneration,  is 
given  as  a  contraindication. 

It  is  generally  conceded  that  ethyl  chlorid  is  not  suitable  for  oper- 
ations, long  or  short,  during  which  absolute  muscular  relaxation  is  de- 
sired. 

ADMINISTRATION 

Experimental  Data. — According  to  Konig,^  a  careful  examination  of 
the  available  literature  concerning  the  dosage  of  ethyl  chlorid  shows 
the  remarkable  fact  that,  up  to  the  present  time,  no  exact  dosage  has 
been  stated.  Very  imperfect  methods  have  been  employed,  which  by  no 
means  permitted  an  accurate  dosage  of  the  ethyl  chlorid  in  the  inspired 
air.  The  quantity  of  the  liquid  narcotic  used  is  not  decisive  for  the 
course  of  the  narcosis,  but  the  decisive  factor  consists  in  the  amount  of 
narcotic  vapor  which  is  mixed  with  the  air  breathed  by  the  patient,  or 
the  laboratory  animal ;  in  other  words,  the  vapor  tension  of  the  inspired 
air.  The  quantity  of  narcotic  taken  up  by  the  blood  and  the  tissue  juices, 
Konig  asserts,  is  dependent  upon  the  ethyl  chlorid  contents  of  the  in- 
spired air;  the  higher  the  latter  (up  to  a  certain  degree),  the  more  is 
taken  up  by  the  blood  from  the  inspired  air.  When  constantly  new  air 
saturated  to  the  same  degree  with  ethyl  chlorid  is  supplied  to  the  in- 
dividual, just  as  much  as  has  already  been  excreted  from  the  blood  will 
be  taken  up  again.  The  contents  of  the  blood  in  ethyl  chlorid,  there- 
fore, will  be  adjusted  to  a  certain  standard  which  is  dependent  upon  the 
contents  of  the  inspired  air  in  these  vapors. 

In  view  of  the  fact  that  the  dose  of  ethyl  chlorid  required  for  nar- 
cosis (meaning  the  smallest  dose  at  which  narcosis  just  begins)  is  not 
known,  Konig  endeavored,  in  a  series  of  experiments,  to  establish  the 
amount  of  the  smallest  narcotizing  dose,  by  the  use  of  accurately  meas- 
ured quantities.  It  was  also  important  to  obtain  in  all  cases  a  complete 
narcosis,  that  is,  a  narcosis  with  less  of  the  corneal  reflex  and  relaxation 
of  the  muscles.     Furthermore,  the  longest  possible  duration  of  the  nar- 

'  Konig:     Loc.  cit.,  147, 


270  ANESTHESIA 

cosis  was  aimed  at,  in  order  to  study  the  effects  of  ethyl  chlorid  in  ex- 
tensive narcoses,  such  as  are  absolutely  necessary  for  operative  purposes. 

The  animals  serving  for  these  experiments  were  frogs  and  rabbits. 
The  latter  were  selected  for  the  reason  that  they  are  best  adapted  to 
experimental  investigations,  and  also  because  all  the  experiments  for  the 
determination  of  the  narcotizing  dose  of  an  anesthetic  agent  have  been 
almost  exclusively  performed  upon  rabbits.  The  ethyl  chlorid  of  Hen- 
ning  (Berlin)  and  the  preparation  of  Kahlbaum  (Berlin)  were  used 
for  these  experiments.  In  order  to  grade  the  dose  with  accuracy,  it  was, 
of  course,  necessary  for  the  preparations  to  be  absolutely  pure.  The 
purity  was  determined  by  passing  the  ethyl  chlorid  vapors  into  water, 
and  ascertaining  that  this  water  neither  reddened  blue  litmus  paper  nor 
became  at  once  opaque  upon  acidulation  with  nitric  acid  and  addition  of 
silver  nitrate. 

A  number  of  experiments  were  performed  on  rabbits,  using  a  mask, 
in  order  to  employ  the  customary  method  of  narcosis  in  the  human  sub- 
ject. The  idea  was  to  obtain  a  short  but  deep  narcosis,  with  muscular 
relaxation  and  disappearance  of  the  corneal  reflex.  The  customary  pro- 
cedure was  therefore  exactly  followed,  meaning  that  doses  of  2  to  5  c.c, 
averaging  4  c.c,  of  ethyl  chlorid,  were  administered  at  the  beginning 
of  the  narcosis,  which  was  then  continued  with  smaller  quantities,  1 
to  2  c.c.  These  narcoses  were  invariably  associated  with  extreme  restless- 
ness on  the  part  of  the  rabbits.  The  most  violent  tonic-clonic  spasms 
appeared  constantly,  and  were  usually  increased  to  an  enormous  in- 
tensity. The  extremely  rapid  onset  of  the  narcosis  was  characteristic  of 
the  experiments  with  the  mask;  the  corneal  reflex  was  usually  lost  as 
soon  as  one  minute  later,  and  deep  narcosis  with  complete  muscular  re- 
laxation set  in.  But  there  again  at  once  appeared  the  rhythmic  twitch- 
ing, typical  for  rabbits,  independent  of  the  respiration,  frequently  lim- 
ited to  the  extremities,  but  often  involving  the  entire  body  of  the  animal. 
Chewing  spasms,  and,  in  consequence,  salivation,  as  well  as  opisthotonos 
and  exophthalmos,  were  almost  invariably  demonstrable.  Eespiration 
was  always  extremely  irritated.  There  was  severe  dyspnea,  rapidly  in- 
creasing to  such  a  degree,  with  concentrated  vapors,  as  to  terminate  at 
last  in  arrest  of  breathing.  On  immediate  removal  of  the  mask,  and  in- 
stitution of  artificial  respiration,  the  breathing  promptly  returned  spon- 
taneously (with  the  exception  of  one  case),  and  the  animal  soon  awoke. 
The  awakening  always  took  place  very  rapidly,  after  one  or  two  minutes, 
as  a  rule,  as  soon  as  the  animals  were  supplied  with  fresh  air.  Other- 
wise the  narcosis  took  the  usual  course  of  prenarcotic  excitement  and 
increased  muscular  tonus;  muscular  relaxation  in  the  stage  of  deep  nar- 
cosis; and  another  postnarcotic  increase  of  the  muscular  tonus,  with  a 
certain  analgesia.  The  pupils  were  usually  dilated,  and  the  eyeballs 
were  prominent,   causing  marked   exophthalmos.     Frequently   distinct 


ETHYL    CHLORID  271 

cyanosis  was  demonstrable.  These  symptoms  were  due  to  vasomotor 
paralysis.  Arrest  of  respiration  invariably  preceded  the  stoppage  of  the 
heart  action,  showing  that  ethyl  chlorid,  on  account  of  its  first  stimu- 
lating and  then  paralyzing  action  upon  the  respiratory  center,  is  not  an 
indifferent  narcotic,  although  the  dangerous  asphyxia  can  usually  be 
prevented,  or  removed,  by  suitable  precautionary. measures. 

The  most  important  results  of  Konig's  experiments,  from  the  stand- 
point of  the  therapeutic  employment  of  ethyl  chlorid,  are  as  follows : 
The  smallest  narcotizing  dose  of  ethyl  chlorid,  for  cold-blooded  animals, 
is  about  2  volume  per  cent  (1.85  vol.)  ;  for  warm-blooded  animals,  about 
4  or  9  volume  per  cent,  respectively.  The  fatal  dose  cannot  be  accurately 
stated.  In  cold-blooded  animals  death  was  caused  with  a  dose  of  about 
15  volume  per  cent.  The  narcotization-zone  of  ethyl  chlorid  is  ex- 
tremely wide.  Although  the  facts  established  upon  rabbits  cannot  all  be 
unconditionally  referred  to  man,  the  efficient  doses  for  man  must  be 
nearly  the  same  as  that  for  rabbits. 

Methods  of  Administration. — The  authors  of  this  volume  are  con- 
vinced, from  a  review  of  the  literature  of  ethyl  chlorid  employed  as  an 
inhalation  anesthetic,  that  the  best  possible  method  for  the  administra- 
tion of  this  agent  has  not  yet  been  evolved.  Theoretically,  the  best  and 
safest  method  of  administration  is  with  warmed,  moistened,  and  oxygen- 
ated vapor  of  ethyl  chlorid.  So  far  as  we  are  aware,  this  method  has 
not  been  employed  in  full,  no  one  having  experimented  with  warmed 
ethyl  chlorid  vapor.  Under  Combinations  and  Sequences  (p.  276)  it 
will  be  seen  that  this  agent  has  been  employed  with  oxygen.  An  appa- 
ratus could  easily  be  devised  for  administering  the  vapor  warmed,  moist- 
ened and  oxygenated,  and  in  definite  amounts,  in  known  percentages  of 
the  combined  vapors.  With  these  modifications  of  technique,  and  with 
the  preliminary  use  of  an  alcoholic  solution  of  oil  of  bitter  orange  peel, 
as  indicated,  doubtless  many  of  the  objections  to  ethyl  chlorid  as  a  gen- 
eral anesthetic  might  be  overcome.  Its  field  of  usefulness  might  like- 
wise be  widened. 

Hewitt  ^  calls  attention  to  two  important  points  in  connection  with 
the  administration  of  ethyl  chlorid  which  help  to  explain  the  incidence 
of  dangerous  symptoms.  "In  the  first  place,"  he  says,  "ethyl  chlorid 
narcosis  is,  by  the  method  now  in  use,  so  rapidly  induced  that  it  is 
usually  difficult  or  impossible  to  recognize  any  stages  or  degrees  in  the 
administration.  In  the  second  place,  the  appearance  of  the  patient  dur- 
ing full  narcosis  is  unattended  either  by  cyanosis  or  pallor — symptoms 
which  with  nitrous  oxid  and  with  chloroform  respectively  indicate  that 
a  sufficiently  large  quantity  of  the  drug  has  been  given.  When  these 
two  points  are  borne  in  mind  it  will  readily  be  seen  that,  unless  proper 
care  is  taken,  the  limits  of  safety  may  readily  be  overstepped,  and  that 

^Hewitt:     Loc.  eit.,  1907,  442. 


272  ANESTHESIA 

the  patient  may  be  plunged,  with  few  if  any  intervening  symptoms,  from 
a  safe  to  a  dangerous  degree  of  narcosis.  If  cyanosis  is  present  it  is 
due  to  'overcrowding.' " 

Open  Method. — The  open  method  of  administration  has  nothing  to 
commend  it  save  its  seeming  safety,  which,  to  the  superficial  observer, 
lies  in  a  large  intake  of  an  unlimited  supply  of  air  together  with  un- 
known quantities  of  ethyl  chlorid. 

An  ordinary  chloroform  mask  is  placed  over  the  patient's  face  and 
ethyl  chlorid  is  administered  drop  by  drop,  or  a  small  stream  of  ethyl 
chlorid  is  intermittently  sprayed  upon  the  mask  until  anesthesia  ensues. 
The  anesthesia  produced  in  this  way  seems  to  be  perfectly  safe,  but  cer- 
tainly no  more  so  than  the  anesthesia  produced  by  Ware's  mask. 

Anesthesia  produced  by  the  open  method  has  been  kept  up  from 
thirty  to  forty  minutes.  Care  must  be  taken  to  stop  its  administration 
immediately  upon  rigidity  or  spasm.  As  long  as  the  respirations  are 
free  and  clear,  there  is  seemingly  no  danger  from  this  method. 

Collapse  is  less  liable  to  occur  after  prolonged  anesthesia  with  the 
open  method  than  with  the  closed. 

Milne,^  who  reports  600  cases  of  ethyl  chlorid  anesthesia,  300  by  the 
open  method  and  300  by  the  closed  method,  from  his  experience,  advo- 
cates the  open  method. 

Malherbe's  ^  method  of  administration  is  as  follows :  A  handkerchief 
is  held  in  the  palm  of  the  right  hand,  which  is  hollowed  out  to  receive  it. 
Into  this  hollow  a  jet  of  chlorid  of  ethyl  is  sprayed,  2  to  4  c.c.  The 
"compress"  is  then  firmly  applied  over  the  mouth  and  nose  of  the  patient, 
who  is  instructed  to  breathe  deeply.  The  head  and  lower  jaw  are  sup- 
ported with  the  left  hand.  "It  is  absolutely  necessary,"  he  says,  "not  to 
allow  any  air  to  be  breathed."  Anesthesia  is  complete  in  30  to  40  sec- 
onds. If  the  operation  is  protracted,  he  renews  the  dose,  claiming  that 
15  c.c.  is  sufficient  for  15-  or  20-minute  operations.  He  also  reports,  from 
a  colleague,  93  operations,  lasting  from  8  to  48  minutes,  the  patients 
varying  from  very  young  infants  to  two  patients  over  80  years  of  age. 

Semi-Closed  Method. — Martin  Ware  ^  has  reported  one  or  two  thou- 
sand cases  without  a  fatality.  The  apparatus  which  he  used  consists  of 
a  rubber  face-piece,  into  which  a  tube  three  to  five  inches  long  is  in- 
serted ;  a  few  layers  of  gauze  are  placed  between  the  tube  and  mask.  A 
stream  of  ethyl  chlorid  is  directed  on  the  gauze  intermittently,  thus  ap- 

^  Milne :  ' '  The  Administration  of  Ethyl  Chloride  by  an  Open  Method, ' ' 
Brit.  Med.  J.,  1911,  1051. 

'"■  Malherbe :  ' '  Chloride  of  Ethyl  as  a  General  Anesthetic, ' '  Med.  Press  and 
Circ,  1911,  91,  461. 

^Ware,  Martin:     Med.  News,  Aug.  3,  1901;  Med.  Sec,  April  6,  1901. 

On  ethyl  chlorid  in  general  anesthesia,  see  A.  M.  Dodge:  Boston  Med.  and 
Surg.  J.,  Feb.  25,  1909,  234.  Leighton  (St.  Louis  Med.  Bev.,  Feb.  16,  1907) 
considers  the  combination  ethyl  chlorid-ether  an  ideal  one. 


ETHYL    CHLORID 


273 


proximating  the  drop  method  of  chloroform;  a  layer  of  hoarfrost  quickly 
forms,  due  to  the  freezing  of  the  watery  vapor  of  the  expired  air.  As 
this  frost  covers  the  gauze,  a  hissing  noise  is  heard  as  the  patient  goes 
into  the  third  stage  of  anesthesia.  If  the  gauze  is  entirely  covered  with 
ice,  the  mask  should  be  immediately  removed  upon  inspiration  and  re- 
placed again  upon  expiration. 

Ware  stated  that  relaxation  can  be  readily  secured  in  children,  and 
also  in  alcoholics,  when  a  preliminary  injection  of  morphin  is  given. 
With  neurotics,  relaxation  is  very  difficult  to  secure.     He  estimated  the 


Fig.  120. — Martin  Ware's  Apparatus  for  Administering  Ethyl  Chlorid. 

failures  at  five  per  cent.  By  failure  was  meant  a  prolonged  period  of 
excitation,  and,  while  the  patient  was  seemingly  narcotized,  the  possi- 
bility of  causing  muscular  rigidity  by  painfid  manipulations. 

Closed  Method. — In  order  to  obtain  the  best  results  from  ethyl 
chlorid,  it  is  necessary  to  employ  a  rubber  bag  large  enough  to  receive 
three  or  four  full  expirations,  and  some  arrangement  for  allowing  the 
ethyl  chlorid  to  enter  the  bag  below  so  that  there  may  be  a  very  gradual 
mixture  of  the  ethyl  chlorid  with  the  expired  air.  The  connections  be- 
tween the  mask  and  the  bag  must  be  large  enough  not  to  interfere  with 
respiration  in  the  slightest  way.  This  being  so,  the  small  tubes  contain- 
ing 3  to  5  c.c.  of  ethyl  chlorid  may  be  easily  attached  to  a  stopcock  of 
any  gas-ether  apparatus.  A  rubber  tube  large  enough  to  hold  the  glass 
ethyl  chlorid  tube  securely  (admitting  the  small  glass  apex  of  the  ethyl 
chlorid  container  well  into  the  caliber  of  the  tube)  may  be  attached  to 
the  bag  as  shown  in  the  illustration  (Fig.  121).  A  piece  of  cotton  or 
gauze  must  be  placed  between  the  end  of  the  glass  tube  and  the  bag  so 
as  to  prevent  any  glass  entering  the  bag.  After  the  bag  has  been  in- 
flated by  the  respirations  of  the  patient,  this  tube  may  be  broken  be- 
tween the  thumb  and  first  two  fingers  of  the  anesthetist's  hand  and  the 
ethyl  chlorid  allowed  to  go  into  the  bag.  When  the  closed  method  is 
followed,  one  or  two  cubic  centimeters  of  ethyl  chlorid  is  sufficient  for 
children,  and  for  feeble  and  anemic  adults.  Five  cubic  centimeters  will 
be  found  sufficient,  as  a  rule,  for  adults,  alcoholics,  and  athletes. 


274 


ANESTHESIA 


Whether  the  patient  is  in  the  recumbent  or  sitting  position,  the  head 
must  be  on  a  line  with  the  body,  thus  insuring  an  absolutely  free  air- 
way. No  pillows  should  be  allowed  under  the  head  unless  some  de- 
formity, such  as  accompanies  rheumatism,  will  not  permit  of  the  head 
going  back.  If  the  operation  is  one  in  which  the  mouth  is  to  be  opened, 
such  as  extraction  of  teeth,  adenoids,  and  tonsils,  and  excision  of  the 
tongue,  a  mouth  gag  must  be  inserted  before  the  administration  com- 
mences, otherwise  difficulty  may  be  experienced  in  opening  the  mouth. 
It  sometimes  happens  that,  even  with  full  surgical  narcosis,  the  masseter 
muscle   may   be   firmly    contracted,   making   it   almost    impossible   to 


Fig.  121. — Ethyl  Chlorid  by  the  Closed  Method. 


pry  the  teeth  apart.  The  duration  of  an  administration  given  by  the 
closed  bag  and  inhaler  can  be  expected  to  be  from  one  to  three  minutes. 

The  administration  is  conducted  as  follows : 

Upon  expiration,  the  mask  is  firmly  applied  to  the  face ;  upon  inspira- 
tion it  is  raised  slightly,  say  from  %  to  14  of  an  inch  from  the  face,  and 
reapplied  immediately,  so  as  to  catch  the  full  expiration.  In  from 
three  to  five  respirations  the  bag  will  be  full,  when  it  must  be  held  firmly 
in  place  upon  the  face.  The  ethyl  chlorid  tube  is  now  broken  and,  if 
at  the  end  of  a  minute  the  patient  is  not  completely  under  the  influence 
of  the  anesthetic,  the  end  of  the  bag  can  be  tilted  up  slightly,  when  the 
ethyl  chlorid  will  mix  more  intimately  with  the  inclosed  air.  In  full 
surgical  anesthesia  the  muscles  are  relaxed,  with  the  exception  of  the 
masseter,  as  stated  before.  The  pulse  is  full  and  bounding  and  increased 
in  rapidity.  The  respirations  in  an  ideal  anesthesia  are  also  full  and 
regular  but  not  as  full  as  with  nitrous  oxid  and  oxygen,  or  with  ether 
by  the  closed  method.  Usually  there  is  some  stertor,  the  eyes  may  be 
fixed  and  turned  downward,  the  pupils  dilated  and  the  lid  reflex  abol- 
ished. There  is  no  cyanosis  or  jactitation.  If  too  large  a  dose  is  given 
or  the  inhaler  is  held  on  the  face  too  long,  there  may  be  a  rigidity  or 


ETHYL    CHLORID 


275 


opisthotonos.    The  color  should  be  pink;   if  cyanosis  or  spasm  is  present 
the  mask  must  be  taken  off  the  face  and  again  reapplied.    . 

The  average  time  required  to  induce  anesthesia  is  one  minute.  If  an 
anesthesia  of  from  five  to  fifteen  minutes  is  required,  a  breath  of  air 
should  be  given  and  the  inhaler  reapplied  about  every  four  to  six  respira- 
tions, with  the  occasional  spraying  of  a  little  ethyl  chlorid  into  the  inhaler. 

The  method  last  described,  of  introducing  ethyl  chlorid  at  the  bot- 
tom of  a  closed  bag  through  a  stopcock,  was  first  proposed  by  Hewitt. 

Hewitt,^  from  the  experi- 
mental work  of  Konig,  and  from 
his  own  clinical  observations,  con- 
cluded that,  "as  with  other  anes- 
thetics, the  effects  produced  by 
ethyl  chlorid  primarily  depended 
upon  its  vapour  tension  in  the  at- 
mosphere presented  to  the  patient. 
But  the  last-named  observations 
tend  to  show  that  there  is  no  defi- 
nite percentage  mixture  the  con- 
tinuous inhalation  of  which  will 
produce  satisfactory  results.  With 
percentage  mixtures  sufficiently 
weak  to  be  respirable  without  dis- 
comfort an  unsatisfactory  type  of 
anesthesia  results;  while  with 
mixtures  sufficiently  concentrated 
to  produce  narcosis  satisfactorily 
the  initial  sensations  are  so  un- 
pleasant as  to  prescribe  such 
initial  vapour  concentration.  So 
far  as  our  present  knowledge  ex- 
tends," he  continues,  "it  would 
seem  that,  with  this  anesthetic, 
the  best  results  are  to  be  obtained 
by  a  rational  and  cautious  use  of 
the  close  system  of  anesthetization,  the  vapour  being  gradually  but  in- 
creasingly added  to  the  to-and-f ro  respiratory  current  till  anesthesia  takes 
place.  We  have  yet  to  ascertain  whether  any  special  concentration  of 
vapour  should  be  aimed  at,  after  consciousness  has  been  destroyed,  and, 
if  so,  how  such  concentration  may  be  secured.  We  have  also  to  deter- 
mine by  future  research  the  relative  influences  of  the  oxygen  limitation 
and  the  carbonic  acid  retention  which  are  involved  in  close  methods  of 
administering  ethyl  chlorid." 

*  Hewitt:     Loc.  cit.,  431. 


Fig. 


122. — Davis    Ethyl  Chlorid-Ethek- 
Inhaler:  Closed  Drop  Method. 


276  ANESTHESIA 

From  his  experience  Hewitt  found  that  if  ethyl  chlorid  is  admin- 
istered to  adults  from  an  open  or  semi-open  inhaler  large  quantities  of 
the  drug  will  be  needed  to  bring  about  even  partial  anesthesia,  the  third 
stage  not  being  attained  in  many  cases.  He  found  that  unsatisfactory 
anesthesia  was  obtained  when  attempts  were  made  to  administer,  by  the 
valveless  method,  percentage  mixtures  of  ethyl  chlorid  and  air,  that  is, 
without  rebreathing.  When  half  the  amount  was  given  by  the  valve- 
less  system  and  the  other  half  by  rebreathing,  the  results  were  still  un- 
satisfactory. He  next  tried  a  definite  ethyl  chlorid  and  air  mixture 
diluted  with  a  further  unknown  quantity  of  air  by  the  valvular  system, — 
the  pure  mixture,  of  known  composition,  being  breathed  by  the  same 
system,  the  remainder  of  the  mixture  being  breathed  by  the  close  system. 
The  results  were  again  unsatisfactory,  swallowing  and  shallow  breathing 
characterizing  the  administration.  A  measured  quantity  (5  c.c.)  of 
ethyl  chlorid  was  next  given  by  means  of  a  Clover  inhaler,  to  which  was 
•attached  a  bag  containing  10,000  c.c.  of  air.  The  expirations  were  at 
first  allowed  to  escape  but  were  retained  during  the  second  half  of  the 
administration.  This  method  proved  more  satisfactory  than  any  of  the 
preceding.  His  final  experiments  were  with  the  following  procedure: 
"(1)  Placing  3,000  c.c.  of  atmospheric  air  in  a  hag;  (2)  allowing  the  pa- 
tient to  commence  rebreathing  this  air;  and  (3)  gradually  diffusing 
therein  a  measured  amount  of  ethyl  cldorid  contained  in  a  small  glass 
tube  connected  with  the  bottom  of  the  bag."  With  this  method  the  re- 
sults were  satisfactory  in  thirteen  cases  in  which  he  first  tried  it,  but  sub- 
sequently it  was  found  to  be  somewhat  less  satisfactory  than  when  the 
patient's  own  expired  air,  as  opposed  to  fresh  air,  was  used  to  partially 
fill  the  inhaling  bag  before  the  introduction  of  the  ethyl  chlorid." 

For  further  information  relative  to  the  administration  of  ethyl 
chlorid,  see  additional  bibliography  at  end  of  chapter. 

Combinations  and  Sequences. — Somnoform. — Somnoform  is  a  mix- 
ture of  5  per  cent  ethyl  bromid,  60  per  cent  methyl  chlorid,  and  35 
per  cent  ethyl  chlorid.  It  is  not  so  stable  as  ethyl  chlorid,  having  a 
greater  tendency  to  decompose,  and,  like  the  latter  drug,  causing  head- 
ache and  vomiting.  It  is  very  seldom  used  in  this  coimtry,  pure  ethyl 
chlorid  being  preferred  by  the  majority  of  those  who  advocate  ethyl 
chlorid  for  any  purpose. 

Anesthol. — Anesthol,  which  was  first  employed  by  Willy  Meyer,^ 
in  1898,  is  a  clear,  transparent  fluid  of  a  very  agreeable  odor.     It  is  a 

^  Meyer,  Willy:  "The  Improvement  of  General  Anesthesia  on  the  Basis  of 
Schleich's  Principles.  With  Special  Eeference  to  Anesthol,"  J.  Am.  Med.  Assn., 
Peb.  28,  1903;  ibid.,  March  7,  1903.  Also  "The  Improvement  of  General  Anes- 
thesia on  Basis  of  the  Principle  of  Adapting  the  Boiling  Point  of  the  Anes- 
thetic to  the  Temperature  of  the  Body  (Schleich) — Ten  Years'  Experience  at 
the  German  Hospital,"  Med.  Bee,  Aug.  15,  1908. 


ETHYL    CIILORID  277 

combination  ^  of  17  per  cent  of  ethyl  clilorid,  35.89  per  cent  of  cliloro- 
form,  and  47.19  per  cent  of  ether.  It  has  a  specific  gravity  of  1.015, 
which,  as  Meyer  points  out,  is  very  close  to  that  of  blood  (1.05G-1.05!)). 
Its  boiling  point  is  104°  F  (40°  C).  For  a  further  exposition  of  the 
principles  involved  in  the  making  and  nse  of  this  preparation  see 
Chapter  XX. 

Meyer's  observations  with  this  anesthetic,  administered  by  means  of 
the  drop  method  and  an  Esmarch  inhaler,"  are  as  follows : 

"1.  Surgical  anesthesia  is  established  in  the  majority  of  cases  in 
about  eight  minutes.  If  morphin  is  previously  administered,  even  this 
time  is  very  frequently  reduced  by  a  few  minutes. 

"2.  The  stage  of  excitation,  if  it  sets  in  at  all,  is  of  very  short 
duration. 

"3.  Complete  anesthesia  having  been  gradually  induced,  the  pulse 
is  full  and  slow — of  the  chloroform-anesthesia  type — and  respiration 
regular,  not  stertorous. 

"4.  In  no  instance  has  there  been  an  increase  in  salivation  or 
bronchial  mucus  during  narcosis. 

"5.  The  face  presents  a  healthy  color.  There  is  no  pallor  nor 
cyanosis. 

"6.  If  too  little  of  the  anesthetic  is  given,  the  patient  will  begin  to 
gag  or  vomit,  as  with  chloroform;  if  too  much  is  administered,  respira- 
tion will  become  shallow,  an,d  eventually,  if  still  more  is  poured  on  the 
mask,  stop  altogether,  but  the  pulse  will  not  be  interfered  with.  In  other 
words,  the  respiratory  and  not  the  circulatory  center  is  first  affected  by 
an  overdose.  .  .  .  The  tendency  throughout  the  narcosis  is  toward  re- 
covery from  the  effect  of  the  anesthetic,  not  toward  a  profound  anes- 
thesia. ... 

"7.  After  the  anesthetic  has  been  stopped,  the  patient  soon  comes 
to,   sometimes  even  while   still  on  the  operating  table.     If  he   sleeps 

^Sollman:  "Pharmacology,"  437.  "The  claim  that  anesthol  is  a  chemical 
compound,  and  that  its  composition  does  not  alter  on  evaporation,  seems  to  be 
lanf  ounded. ' ' 

^  Neef  ("Practical  Points  in  Anesthesia")  states  that  at  the  German  Hos- 
pital it  is  the  practice  to  employ  a  Schimmelbusch  mask,  covered  with  flannel, 
over  which  impermeable  cloth,  with  a  lozenge-shaped  fenestrum  the  size  of  a  ten- 
cent  piece,  is  placed.  He  also  states  that  it  requires  15-20  c.c.  for  induction, 
and  40-60  c.c.  for  narcosis.  It  is  now  the  routine  custom  at  this  institution  to 
administer  a  hypodermic  of  morphin,  1  /12  to  %  gr.,  one-half  to  three-quarters  of 
an  hour  before  anesthesia.  Cardiac  collapse  occurs  during  induction,  if  at 
all.  This  is  indicated  by  weak  pulse  and  pallid  face.  A  change  to  ether  by  the 
drop  method  will  quickly  remedy  this.  When  stimulants  are  needed  at  any 
other  time,  a  few  drops  of  ether  may  be  added.  With  anesthol  the  volume  of  the 
pulse  may  be  expected  to  decrease  about  one-third  in  the  course  of  an  hour,  and  as 
much  as  one-half  in  a  two-hour  anesthesia.  "Crowding"  is  the  cause  of  sali- 
vation or  Cyanosis  during  anesthesia,  and  of  excessive  vomiting  afterward. 


278  ANESTHESIA 

longer,  it  is  usually  on  account  of  the  previously  administered  morphin. 

"8.  Vomiting  occurs  in  a  small  percentage  of  cases  after  return  to 
consciousness.    It  is,  however,  not  of  a  prolonged  or  distressing  type. 

"9.  Untoward  after-effects,^  such  as  bronchitis,  pneumonia,  ne- 
phritis, are  not  seen  as  a  result  of  anesthesia  with  this  mixture.  A  pre- 
existing catarrh  of  the  bronchi  or  inflammation  of  the  kidneys  may,  of 
course,  become  somewhat  aggravated  for  a  few  days,  but  never  to  the  ex- 
tent that  may  happen  after  the  inhalation  of  other  gaseous  substances. 
These  complications  certainly  are  never  produced  by  this  anesthetic. 

"10.  Patients  afflicted  with  serious  valvular  cardiac  lesions,  chronic 
pulmonary  afl'ections,  atheromatosis,  diabetes,  profound  anemia,  or  other 
complications  of  serious  character  have  stood  this  preparation  most 
satisfactorily;  contrary  to  what  one  would  be  justified  in  expecting  in 
such  cases,  a  better  circulatory  and  respiratory  condition  was  induced 
during  anesthesia. 

"11.  The  total  quantity  used  is  generally  small.  Our  narcotizers 
very  often  carry  a  patient  through  an  anesthesia  lasting  from  one  to  two 
hours,  with  two  to  three  ounces." 

For  further  information,  especially  in  reference  to  the  chemistry  of 
anesthol,  see  Chapter  XX. 

Ethyl  Ciilorid  and  Oxygen. — Lotheissen  ^  proposes  an  improve- 
ment of  ethyl  chlorid  narcosis  by  means  of  the  simultaneous  inhalation 
of  ethyl  chlorid  and  pure  oxygen.  For  this  purpose,  he  constructed  an 
apparatus  which  is  a  modification  of  the  Eoth-Drager  apparatus,  for  hos- 
pital practice;  also  a  smaller,  cheaper  apparatus  which  can  be  easily 
transported  to  the  patient's  dwelling.  This  new  method  of  ethyl  chlorid 
narcosis  has  been  used  by  him  for  five  years  past,  without  unfavorable  ex- 
periences, in  about  five  hundred  anesthesias.  The  usual  duration  of  an- 
esthesia was  ten  minutes,  only  a  small  number  being  longer  than  twenty 
minutes.  The  average  quantity  of  ethyl  chlorid  administered  per  min- 
ute amounted  to  1  to  2  c.c.  with  II/2  liters  oxygen.  In  cases  concerning 
habitual  users  of  alcohol,  in  whom  anesthesia  could  not  be  obtained 
within  two  or  three  minutes,  a  few  drops  of  ether  were  added,  resulting  in 
a  mixed  narcosis  of  ethyl  chlorid  and  ether  with  oxygen.  In  Lotheis- 
sen's  experience,  it  is  not  advisable  to  pass  to  chloroform  or  its  mixtures 
after  the  beginning  of  the  narcosis  with  ethyl  chlorid.  In  order  to  avoid 
asphyxia,  in  consequence  of  concentrated  vapors,  the  oxygen  is  allowed 
to  escape  before  the  ethyl  chlorid  is  inhaled.  The  pulse-rate  and  res- 
piratory frequency  are  not  affected,  as  a  rule.  Vomiting  is  less  common 
than  with  other  narcotics.  After-effects  are  always  trifling  and  transi- 
tory.   Although  Lotheissen  admits  hardly  any  contraindications,  he  does 

^  Torek,  F. :     "  Anesthol  Poisoning   Causing  Acute  Yellow  Atrophy   of  Liver 
After  Operation  for  Ileo-colic  Intussusception,"  Am.  Surg.  J.,  1910,  52,  489-492. 
'  Lotheissen :     Loc.  cit. 


ETHYL    CHLORID  279 

not  employ  the  ethyl  chlorid-oxygen  narcosis  in  those  cases  where  it  is 
advisable  to  avoid  general  anesthesia. 

Eosenthal  and  Berthelot  ^  have  found  that  a  mixture  of  oxygen  and 
ethyl  chlorid,  instead  of  ethyl  chlorid  alone,  produces  very  satisfactory 
anesthesia,  even  to  one  hour's  duration.  In  1906  they  stated  that  all  the 
experiments  had  been  conducted  upon  animals. 

Ethyl  Chlorid  and  Nitrous  Oxid. — Ethyl  chlorid  has  been  given 
by  one  of  the  authors  (J.  T.  G;)  with  nitrous  oxid  and  oxygen  in 
a  number  of  cases,  thus  securing  complete  relaxation,  otherwise  unobtain- 
able with  the  latter  combination.  Ethyl  chlorid  may  be  sprayed  into 
the  inhaler  or  through  an  inspiratory  valve.  The  only  objection  to  using 
ethyl  chlorid  in  this  way  is  the  fact  that  considerable  vomiting  occurs 
immediately  after  the  removal  of  the  mask. 

Ethyl  Chlorid  with  Ether. — The  ethyl  chlorid-ether  sequence 
is  given  in  the  same  way  as  the  nitrous  oxid-ether  sequence,  that  is, 
with  any  of  the  closed  inhalers.  As  the  patient  gets  well  under  the 
ethyl  chlorid,  the  ether  is  turned  on  gradually.  The  technique  of  the 
administration  is  as  follows : 

Attach  a  tube  containing  3  to  5  c.c.  of  ethyl  chlorid  to  the  stop- 
cock of  the  bag  by  a  rubber  tube.  As  the  patient  fills  the  bag  three- 
fourths  full,  break  the  neck  of  the  tube  of  ethyl  chlorid  and  thus  allow 
the  ethyl  chlorid  to  enter  the  bag.  As  the  patient  sinks  under  the  ethyl 
chlorid,  turn  on  the  ether  very  gradually. 

Ethyl  Chlorid  with  Chloroform. — Ethyl  chlorid  should  not  be 
administered  preliminary  to  chloroform,  inasmuch  as  both  of  these 
agents  are  respiratory  depressants,  both  are  cardiac  poisons,  and  both 
act  quickly.  They  have  been  used  in  this  way,  but  this  sequence  should 
be  avoided  because  it  is  dangerous. 

BIBLIOGRAPHY 

Blumfield :  "Eecent  Work  in  the  Field  of  Anesthetics."  The  Prac- 
titioner, 1903,  420. 

Braine,  Carter:  "The  Administration  of  Ansesthetics  in  Dental 
Surgery."    Brit.  Dent.  J.,  Oct.,  1904,  717. 

Buxton,  Dudley :  "Operations  on  the  Upper  Passages  from  the 
Anaesthetist's  Point  of  View."    The  Practitioner,  Jan.,  1905,  77. 

Chaldecott,  J.  H.,  and  Stephenson :  "Ethyl  Chloride  as  a  General 
Anaesthetic  in  Eye  Work."    The  Ophthalmoscope,  April,  1904,  129. 

Daniells,  G.  W.  B. :  "The  Administration  of  Ethyl  Chloride."  Brit. 
Med.  J.,  1904,  949. 

De  Prenderville :  "Advantages  of  Ethyl  Chloride  Anaesthesia." 
The  Lancet,  1904,  978. 

^Eosenthal  and  Berthelot:     Compt.  rend.,  146,  43. 


280  ANESTHESIA 

Memming,  A.  L. :  "Ethyl  Chloride:  A  Few  Practical  Remarks." 
Bristol  Med.  CUr.  J.,  Sept.,  1904,  228. 

Hatch,  E.  M. :  "Chloride  of  Ethyl  as  a  Dental  and  General  Anaes- 
thetic."    Brit.  Dent.  J.,  Oct.,  1903,  638. 

Hewitt,  E.  W. :  "Anesthetic  Effects  of  Ethyl  Chloride."  The  Lan- 
cet, 1904,  1408  and  1486. 

Hilliard,  Harvey :  "Ethyl  Chloride  as  an  Anesthetic  in  General 
Practice."    The  Practitioner,  Feb.,  1905,  203. 

Luke,  T.  D. :  "The  Use  of  Ethyl  Chloride  as  a  General  Ana?sthetic." 
Edinburgh  Med.  J.,  1903,  425. 

Lynch,  Jerome  M. :  "The  Choice  of  an  Anesthetic  in  Anal  Sur- 
gery."    Va.  Med.  Semi-Monthly,  July  24,  1908. 

McCardie,  W.  J.:  "Ethyl  Chloride  as  a  General  Anesthetic."  The 
Lancet,  1903,  952  and  1198. 

Seelig,  M.  G. :  "Combined  Ethyl-Chloride  and  Ether  Anesthesia." 
St.  Louis  Courier  of  Med.,  Feb.,  1905. 

Ware,  Martin  W. :  "One  Thousand  Personally  Conducted  Cases  of 
Ethyl  Chloride  Narcosis."    J.  Am.  Med.  Assn.,  Nov.  8,  1902. 


CHAPTER  VII 

CHLOROFORM 

Chemistry  :  History ;  History  of  Its  Use  as  an  Anesthetic ;  Proper- 
ties; Uses;  Preparation  of  Chloroform;  Impurities  Liable  to  Be  Present 
in  Chloroform ;  Stability  of  Chloroform ;  Decomposition  of  Pure  Chloro- 
form; Pole  of  Alcohol  in  Anesthetic  Chloroform;  Character  of  Contain- 
ers; Stoppers  for  the  Containers;  The  Changes  Which  Anesthetic  Chloro- 
form Undergoes  When  a  Current  of  Oxygen  Is  Conducted  Through  It; 
The  Decomposition  of  Chloroform  Vapor  Upon  Exposure  to  Gas  Light, 
etc.,  During  Administration;  Effect  of  Agitation  Upon  Anesthetic  Chlo- 
roform; Standards  of  Purity  for  Anesthetic  Chloroform. 

Special  Physiology  :  Effects  Upon  the  Eespiratory  System ;  Effects 
Upon  the  Circulatory  System;  Effects  Upon  the  Nervous  System;  Ef- 
fects Upon  the  Muscular  System;  Effects  Upon  the  Glandular  System 
and  Other  Structures ;  Causes  of  Death  from  the  Administration  of  Chlo- 
roform ;  Stages  of  Anesthesia ;  Elimination. 

Indications  and  Contraindications  :  Indications ;  Contraindi- 
cations; Af ter-Effects ;  Comparison  with  Other  Agents. 

Administration  of  Chloroform  :  Drop  Method ;  Other  Methods  of 
Administration;  The  Eoth-Drager  Oxygen  and  Chloroform  Apparatus; 
Vernon  Harcourt's  Inhaler;  Junker  Apparatus;  Braun's  Inhaler; 
Gwathmey  Three-Bottle  Vapor  Inhaler. 

CHEMISTRY 

History. — Chloroform,  CHCI3  (trichlormethane,  methenyl  trichlorid, 
dichlorinated  chlorid  of  methyl,  perchlorid  of  formyl,  formyl  trichlorid), 
was  independently  discovered  in  1831  by  Guthrie,  Soubeiran,  and 
Liebig,^  yet  it  has  been  asserted  that  there  are  indications  of  an  ear- 
lier acquaintance  with  the  compound.  For  example,  we  are  told  by 
Hutman,2  on  the  authority  of  Johannes  Porta  ^  and  Sir  Walter  Scott,^ 

1 A   fuller   historical  account  may  be  had  in  Appendix  II,  p.   871. 

2  J.  CJiim.  med.   (3),  4,  476. 

^"  Magna  Naturalis, "  1619.  It  should  be  mentioned  here  that  in  1589  Giau- 
battista  Porta  used  an  essence  made  from  hyoscyamus,  solanum,  poppy  and 
belladonna,  enclosed  in  a  lead  vessel,  for  producing  sleep  by  inhalation  of  the 
vapor. 

*  ' '  Letters  on  Demonology  and  Witchcraft, ' '  1830. 

281 


282  ANESTHESIA 

that  chloroform  was  known  in  former  times  and  was  then  employed  as  a 
means  of  producing  insensibility.  Investigation  shows  that  this  state- 
ment is  based  upon  misinterpretation.^ 

History  of  Its  Use  as  an  Anesthetic. — In  March,  1847,  Flourens 
announced  to,  the  Academy  of  Sciences  of  Paris  that  chloroform  exer- 
cised on  the  lower  animals  an  anesthetic  action  analogous  to  that  of 
ether.  In  the  same  year  Doctor  (afterwards  Sir)  J.  Y.  Simpson, 
looking  for  a  more  convenient  and  less  objectionable  anesthetic  than 
ether,  consulted  Mr.  Waldie,  a  chemist  of  Liverpool,  who  suggested  that 
he  use  chloroform.  In  November,  1847,  he  read  a  paper  entitled  "No- 
tice of  a  New  Anaesthetic  Agent  as  a  Substitute  for  Ether  in  Surgery 
and  Midwifery."    From  this  time  on  its  use  spread  rapidly. 

In  January,  1848,  Hannah  Greener,  the  first  victim  to  chloroform, 
died  at  Winlaton  near  Newcastle,  Dr.  Meggison  being  the  chloroformist. 
It  may  be  appropriate  to  relate  exactly  under  what  circumstances  she 
died.  The  operation  was  for  an  ingrown  toe-nail.  The  girl  was  seated 
in  a  chair  and  only  a  few  whiffs  of  chloroform  were  administered,  and 
she  died.  She  was  only  eighteen  or  twenty  years  of  age.  The  history 
of  this  first  case  is  given  in  detail  for  the  reason  that  so  many  of  the 
physiological  principles  relating  to  chloroform,  as  we  know  them  to-day, 
were  violated  on  that  occasion,  namely : 

First :    It  was  administered  with  the  patient  in  an  upright  posture. 

Second:    It  was  administered  for  a  minor  operation. 

1  Most  ancient  authors  who  pretend  to  treat  of  the  wonders  of  natural  magic 
give  recipes  for  calling  up  phantoms  by  the  inhalation  of  certain  gases  from 
burning  medicated  mixtures,  generally  of  oils,  and  by  the  use  of  suffumigations 
of  strong  herbs  (Hibbert's  "Apparitions,"  120).  The  ancient  Egyptians,  As- 
syrians, and  Chinese  were  familiar  with  many  vegetable  substances  (e.  g.,  can- 
nabis indica)  capable  of  producing  ecstatic,  sedative,  and  anodyne  effects  (Snow's 
"Chloroform  and  Other  Aneesthetics, "  1858;  Bernard's  "Lemons  sur  les  anes- 
thesiques  et  sur  I'asphyxie, "  1875;  Lyman's  "Artificial  Anesthesia  and  Anes- 
thetics," 1883;  and  Dastre's  "Les  anesthesiques, "  1890).  From  the  "Odys- 
sey" (iv.,  220)  we  learn  that  Helen  '^cast  a  drug  into  the  wine  whereof  they 
drank,  a  drug  to  lull  all  pain  and  anger  and  bring  forgetfulness  of  every  sor- 
row." Herodotus  refers  to  the  custom  of  the  Scythians  of  inhaling  the  fumes  of 
a  kind  of  hemp;  Disscorides  (De  Med.  Mat.,  iv.,  76)  makes  mention  of  the  prac- 
tice of  boiling  in  wine  the  root  of  the  Atropa  Mandragora  and  of  administer- 
ing some  of  the  decoction  prior  to  surgical  operations;  and  Pliny  (xxxv.,  94) 
refers  similarly  to  the  powers  of  the  mandrake.  Mandragora  appears  to  have 
been  used  to  some  considerable  extent  (Galen,  lib.  vii.,  207;  Lucian,  "Demos- 
thenes Ecomium, "  36);  it  was  employed  in  compounding  the  "spongia  som- 
nif era ' '  of  Theodoric.  The  Bible  and  the  Talmud  also  contain  references  to 
ancient  practices  of  inducing  sleep  by  artificial  means.  However,  excepting  the 
use  of  Memphis  marble  and  vinegar  as  a  local  anesthetic  by  the  Eomans,  carotid 
compression  and  (later)  mesmerism,  vegetable  narcotics  only  were  used  to  as- 
suage suffering  and  for  the  induction  of  unconsciousness  until  the  foreshadowing 
of  the  modern  system  of  anesthesia  by  the  discovery  of  nitrous  oxid. 


CHLOROFORM  283 

Third:    It  was  administered  to  a  patient  with  high  nervous  tension. 

Fourth :    It  was  probably  administered  in  a  concentrated  dose. 

Fifth:  To  a  young,  vigorous  woman.  There  would  be  no  justifica- 
tion for  such  a  fatality  with  our  present  knowledge. 

Ten  years  after  its  introduction  as  an  anesthetic,  Dr.  John  Snow 
published  his  classical  work  on  "Chloroform  and  Ether  Anaesthesia," 
giving  among  other  things  an  exact  percentage  of  chloroform  and  appa- 
ratus for  administration  of  the  same. 

In  1879  the  first  committee  on  the  British  Medical  Association  met 
and  condemned  the  use  of  chloroform.  In  1890,  the  second  Hyderabad 
committee  met  and  concluded  that  chloroform  was  a  comparatively  safe 
drug  when  properly  used.  In  1901  the  British  Medical  Association 
committee  published  a  second  report  condemning  the  indiscriminate  use 
of  chloroform.  In  the  same  year  Dr.  Frederick  Hewitt  issued  a  second 
edition  of  his  work  on  anesthetics,  stating  (page  497)  that  with  a  com- 
pound sequence  (NoO-Ether-CHCl.,)  it  is  possible  to  proceed  to  deep 
chloroform  anesthesia  with  safety  and  smoothness. 

In  1904  one  of  us  (J.  T.  G.)  read  a  paper  at  a  meeting  of  the  Sur- 
gical Section  of  the  New  York  Academy  of  Medicine,  showing  that  the 
value  of  chloroform  was  more  than  doubled  when  used  with  oxygen  in- 
stead of  air,  and  also  stating  that  this  combination  was,  theoretically  at 
least,  safer  than  ether  and  air. 

In  1906  ^  one  of  the  authors  of  this  book  (J.  T,  G.)  read  another 
paper  before  the  American  Medical  Association,  drawing  attention  to  the 
remarkable  difference  between  warm  and  cold  chloroform  vapor,  and 
giving  reasons  why  chloroform  should  be  preferred  in  the  Southern 
States,  Cuba,  Philippines,  and  in  any  of  the  tropical  countries. 

Properties. — Chloroform  is  a  colorless,  limpid  liquid,  possessing  a 
sweet  but  somewhat  burning  taste  and  an  agreeable  "ethereal"  odor. 
When  absolutely  pure,  it  possesses  a  density  of  1.49887  at  15/4°  and 
boils  at  -|-61.2°  C.  Pure  chloroform  decomposes  under  certain  condi- 
tions, which  will  be  referred  to  later,  and  should  never  be  used  for  anes- 
thesia. Anesthetic  chloroform  does  and  should  contain  0.25  to  1.00  per 
cent  of  ethyl  alcohol,  which  acts  as  a  preservative.  Therefore  anesthetic 
chloroform  may  have  a  specific  gravity  of  not  less  than  1.476  at  25/25°.- 

^ "  A  Plea  for  the  Scientific  Administration  of  Anesthetics, ' '  J.  Am.  Med. 
Assn.,  Oct.  27,  1906,  47,  1361-1364. 

2  The  anesthetic  chloroform  on  the  American  market  varies  in  specific  gravity 
from  1.4730  to  1.4827  at  25/25°,  usually  in  close  proximity  to  1.476,  the  mini- 
mum density  permitted  by  the  Pharmacopoeia. 

The  samples  of  chloroform  of  German  manufacture  examined  by  Baskerville 
and  Hamor  {loc.  cit.)  varied  in  specific  gravity  from  1.487  to  1.492  at  15/15°, 
although  one  sample  possessed  a  density  of   1.497  at  this  temperature. 

The  specific  gravities  of  the  chloroforms  recognized  as  official  by  the  pharmaco- 
pceias  of  various  countries  are  given  in  the  following  table:   (Continued  on  p.  284) 


284 


ANESTHESIA 


When  pure,  chloroform  is  not  combustible;  but  when  mixed  with 
alcohol,  it  burns  with  a  smoky  flame  edged  with  green.  Chloroform  is 
slightly  soluble  in  Avater  (0.822  gm.  per  100  gm.  water  at  30°  C.)  and  it 
imparts  to  it  a  sweet  taste.  It  is  miscible  in  all  proportions  with  abso- 
lute alcohol,  ether,  benzene,  and  petroleum  spirit.  It  is  soluble  to  a  lim- 
ited extent  in  aqueous  alcohol.  It  may  be  made  into  an  emulsion  with 
water  by  means  of  saponin.  Chloroform  is  an  important  technical  sol- 
vent; it  dissolves  fats,  certain  components  of  india-rubber,  resins,  sul- 
phur, phosphorus,  iodin,  various  alkaloids,  many  alkaloidal  salts,  as  well 
as  many  other  organic  compounds.^ 

Uses. — Chloroform  is  used  in  medicine  as  an  anesthetic,"  stimulant, 
antispasmodic,  counterirritant,  antiseptic ;  ^  as  an  antidote  in  cases  of 

(Continued  from  p.  283) 
DENSITIES   AT    15°   ACCORDING   TO   VARIOUS   PHARMACOPCEIAS 


1.480 

1.489 

1.490 

1.497 

1.498 

1.500 

1.485- 
1.489 

1.485- 
1.490 

Spain 

Portugal 

Mexico 

Switzerland 

Greece 

Chili 

France 

Roumania 

Germany 

Denmark 

Hungary 

Norway 

Sweden 

Finland 

Belgium 

1.485-1.495 


1.490-1.500 


1.490-1.493 


1.490-1.495 


1.498-1.500 


1.499-1.500 


Not  below 
1.476 
at  25° 


Japan 


Austria 


Italy 


Great  Britain 


Holland 


Russia 


United  States 


The  chloroform  constants  according  to  various  editions  of  the  United  States 
Pharmacopoeia  are  as  follows: 

Date  Density  at  15°  Boiling  Point 

1851 1.49  142°  F. 

1869 1.490-1.494  140°  F. 

1873 1.480  142°  F. 

1882 1.485-1.490  60-61°  C. 

1893 Not  below  1 .490  60-61°  C. 

'See,  in  this  connection,  Pettenkofer:  Jahresber.,  1858,  363;  Schlimpert: 
7bid,  1859,  405;  Nowak:  Archiv  PJiarm.  (3),  J,  281;  Hesse:  Pharm.  J.   (3)  ^,649. 

^Sir  James  Simpson:  "New  Anesthetic,"  1847,  7;  Illust.  London  News, 
Dec.  4,  1847,  370-2;  E.  B.  Simpson:  Century,  B5,  412;  Liv.  Age,  66,  720; 
J.  Med.  Sci.,  Sept.,  1847;  Ed7ib.  Medico-Chir.  Soc.,  Nov.  11,  1848;  J.  Y.  Simp- 
son's "Anesthesia,"  1849,  93,  145,  182,  193,  203. 

*  As  an  antiseptic,  chloroform  prevents  the  growth  of  micro-organisms,  but  it 
does  not  affect  the  action  of  soluble  ferments  (J.  Soc.  Chem.  Ind.,  1886,  331).  On 
the  antiseptic  applications  of  chloroform,  see  Eobin:  Compt.  rend.,  SO,  52;  Au- 
gendre:  Ibid.,  31,  679;  Barnes:  Pharm.  J.  (3),  5,  441;  Salkowski:  Chem. 
Beport.,  1888,  166;  and  Pharm.  J.  (3),  18,  315,  356,  855. 


CHLOROFORM  285 

strychnin  poisoning,  and  as  an  analgesic;  tccbiiically  in  ol(!ctrol(;clinics, 
rubber  industry,  and  piiotograpby  ;  and  in  dentistry  as  a  solvent. 

Preparation  of  Chloroform.' — Chloroform  is  made  from  alcohol,  ace- 
tone, or  "methylated  spirit,"  by  treatment  with  chlorid  of  lime 
("bleach"),  other  hypochlorites,  or  electrolysis  of  a  halogen  salt  in  the 
presence  of  the  first  mentioned  substances.  It  is  also  made  from  carbon 
tetrachlorid  by  reduction,  the  tetrachlorid,  as  a  rule,  being  previously 
made  from  carbon  disulphid. 

Impurities  Liable  to  Be  Present  in  Chloroform.— The  impurities 
liable  to  be  present  may  be  from  the  variety  of  materials  used  in  the 
manufacture  of  chloroform  just  noted,  and  changes  the  product  is  liable 
to  undergo  on  keeping,  which  will  be  considered  later  from  chemical  and 
physiological  standpoints. 

Impurities  from  the  Manufacturer. — These  are  usually  the  so- 
called  "organic  impurities,"  which  are  found  in  considerable  amounts  in 
a  chloroform  which  has  been  made  from  poorly  rectified  spirit,  acetone, 
or  carbon  tetrachlorid  (the  sources),  if  impure  chemicals  have  been 
employed  in  the  manufacture  or  subsequent  rectification  and  purifica- 
tion, or  if  the  chloroform  has  not  been  properly  purified.  These  im- 
purities, even  though  some  may  not  be  of  much  importance  from  a 
physiological  standpoint,  must  still  be  given  attention,  since  an  im- 
pure chloroform  is  likely  to  become  altered  through  oxidation  during 
storage,  notwithstanding  the  fact  that  pure  ethyl  alcohol  has  been 
added. 

The  possible  impurities  of  this  class  are  as  follows:  Excess  water; 
excess  alcohol;  acetone;  methyl  alcohol;  carbon  tetrachlorid;  tetra- 
chlorethylene,  hexachlorethane,  etc. ;  aldehyds ;  amyl,  propyl,  and  butyl 
alcohols,  and  compounds;  ether  ";  acids  (sulphuric,  hydrochloric,  formic, 
acetic)  ;  metallic  chlorids ;  ethyl  chlorid ;  ethylene  chlorid ;  ethylidene 
chlorid^;  ethyl  acetate;  oils  ("empyreumatic,"  "pyrogenous,"  "chlori- 
nated"); fixed  and  extractive  matter. 

Purification  in  Manufacture. — Some  of  the  impurities  are 
washed  out  with  water,  others  are  removed  by  treatment  alternately  with 
concentrated  sulphuric  acid  and  sodium  carbonate.  This  product  is  then 
further  purified  by  fractional  distillation.  The  details  of  treatment 
would  be  out  of  place  here,  however.  Interesting  facts  appear  in  Appen- 
dix II,  page  871. 

Impurities  Liable  from  Improper  Storage. — Although  the  ra- 
tionale of  their  development  will  be  discussed  in  later  paragraphs,  the 

1  Further  details  are  given  in  Appendix  II,  p.   871. 

2  From  1865  to  1875,  ether  was  considered  as  one  of  the  general  contaminants 
of  chloroform. 

3  About  1880,  ethylidene  chlorid  was  regarded  as  a  general  impurity  of  chloro- 
form. 


286  ANESTHESIxi 

possible  impurities  of  this  class  may  be  conveniently  enumerated  here. 
They  are :  Acetaldehyd ;  acetic  acid ;  formic  acid ;  carbonyl  chlorid ; 
hydrochloric  acid;  hydrogen  dioxid;  chlorin;  chlorinated  derivatives 
of  alcohol  oxidation  products. 

These  impurities  are  dealt  with  specifically  in  Appendix  II  on  page 
871. 

Physiological  Considerations  in  Eespect  to  Impurities. — 
Huchard  ^  has  said,  "Pure  chloroform,  well  given  to  a  patient  prepared 
for  it,  almost  never  kills."  Serious  results  have  occurred  from  the  use 
of  anesthetic  chloroform  containing  foreign  substances,  and  although  the 
grades  at  present  sold  as  chloroform  for  anesthesia  hardly  contain  suffi- 
cient impurities  which  can  be  held  responsible  per  se  for  deaths  which 
have  occurred  during  narcosis,  yet  the  presence  of  these  products  may 
account  for  some,  at  least,  of  the  disagreeable  after-effects  so  often  no- 
ticeable following  the  administration  of  some  chloroform.^  Conse- 
quently, anesthetic  chloroform  should  comply  with  the  most  rigid  tests,^ 
and  the  preparation  which  conforms  with  these  requirements,  and  at  the 
same  time  is  comparatively  less  likely  to  decomposition  than  others  also 
answering  the  same  tests,  should  at  all  times  be  preferred  to  a  cheaper 
but  less  stable  grade.  According  to  the  investigations  of  Feigl  and 
Meier,*  the  customary  chemical  examination  of  a  sample  of  anesthetic 
chloroform  is  not  conclusive,  but  requires  confirmation  by  biological 
tests.    Most  important,  however,  is  clinical  experience. 

In  regard  to  the  fatal  results  which  have  been  obtained  in  practice 
following  the  use  of  chloroform  vapor  for  the  induction  of  anesthesia,  a 
considerable  percentage  of  cases,  especially  those  where  death  has  ensued 
immediately  upon  first  inspiration,  may  not  be  due  to  the  action  of 
chloroform  at  all.'^     However,  Simpson  ®  enumerates  a  number  of  cases 

*  J.  des.  Tract.,  May  31,  1902. 

-We  have  private  information  as  to  ill  effects  from  chloroform  supplied  by- 
certain  dealers. 

*  The  pharmacopoeial  tests  are,  in  general,  insufficient,  and  samples  of  chloro- 
form may  comply  with  the  tests  prescribed  by  various  pharmacopoeias,  and  yet 
important  differences  may  be  shown  to  exist  among  them  by  means  of  other 
tests.  These  facts  have  been  brought  out  by  Langaard  {Therap.  Monatsh.,  May, 
1902).     Our  opinions  will  be  found  in  this  book. 

*  Biochem.  Z.,  1906,  316.  Feigl  and  Meier  marked  out  the  blood-pressure 
curves  on  a  drum  by  means  of  a  kymograph;  healthy  dogs  were  made  to  inhale 
equal  quantities  of  chloroform  of  different  makes  through  a  tracheal  canula. 
The  results  obtained  showed  that  the  different  brands  of  chloroform,  although 
they  appeared  almost  identical  by  the  chemical  tests,  differed  considerably  in 
their  liability  to  cause  a  diminution  in  blood  pressure  and  to  cause  arhythmia 
of  the  pulse  beat. 

5  See,  in   this  connection,   Nussbaum:      Eandh,   d.   allg.   p.  spec.   Chir.,   1867, 
612;  Lawrie:     Lancet,  1890,  i,  149. 
6j?nt  Med.  J.,  1870,  i,  199. 


CHLOROFORM  287 

antedating  the  general  introduction  of  anesthesia  which  may  be  classed 
as  "chloroform  deaths."  ^ 

In  all  indubitable  cases  the  nature  of  the  chloroform  administered 
certainly  plays  an  essential  role;  this  fact  is  supported  by  convincing 
evidence,  even  though  the  percentage  of  deaths  caused  by  chloroform 
administered  during  operations  is  unaccountably  different  in  different 
years,  times,  and  places.  We  can  only  attribute  the  existing  diversity  of 
opinion  on  the  subject  to  the  degrees  of  purity  of  the  anesthetic  used, 
the  different  modes  of  administration,  the  varying  lengths  of  the  time 
of  anesthesia,  the  varying  severity  of  the  operation,  and  the  state  of  the 
patient. 

According  to  almost  all  authorities,  the  first  danger  from  the  use 
of  chloroform  consists  in  an  interruption  of  respiration,^  and  it  has 
been  said  that  only  after  the  observation  of  the  pulse  had  superseded 
that  of  respiration  did  chloroform  deaths  become  more  frequent.^  Ex- 
perience has  therefore  clearly  shown  that  every  obstacle  to  respiration 
must  be  removed;  the  presence  of  irritating  contaminants  in  the  anes- 
thetic must,  as  a  consequence,  be  guarded  against.*  In  France  Sedil- 
lot,^  who  laid  the  greatest  stress  on  the  purest  chloroform,  did  not  have 
to  record  a  single  death;  but  in  nine-tenths  of  all  the  chloroform  deaths 
on  record  not  a  word  is  said  in  regard  to  the  article  employed,  and 
consequently  an  important  factor  for  forming  an  opinion  is  entirely 
excluded.® 

1  Sansom  ("Chloroform,"  London,  1865)  put  the  average  mortality  at  0.75 
per  10,000;  Eichardson  (Med.  Times  and  Gas.,  1870)  at  2.8;  and  Morgan  (Med. 
Soc.  Va.,  1872),  at  3.4. 

2  Metcalfe  (Trans.  N.  Y.  Acad.  Med.,  1,  145)  stated  in  1850  that  his  experi- 
ence, extending  then  to  800  administrations,  went  to  substantiate  the  fact  that 
the  use  of  impure  chloroform  causes  headache,  nausea,  and  bronchial  irritation. 

3  Hewitt:     Proc.  Boij.  Med.  and  CMr.  Soc.,  890. 

*  Occhini  [Pharm.  J.  (3),  8,  988]  came  to  the  conclusion  that  the  tolerance 
of  chloroform  can  be  assured  by  the  preventive  use  of  ammoniacal  inhalations. 
Although  chloroform  and  ammonia  have  a  mutually  antagonistic  action  on  the 
heart,  according  to  Einger  (Practitioner,  1881,  19),  such  a  method  is  unneces- 
sary if  pure  chloroform  of  anesthetic  grade  is  properly  administered  to  a  pa- 
tient prepared  for  it. 

5  Bull.  Soc.  CMr.,  7,  1881. 

6  Some  exceptions  may  be  noted  here.  Dr.  Hunter  McGuire,  surgeon  in  the 
Confederate  Army  during  the  Civil  War,  at  one  time  remarked  that  chloroform 
had  been  administered  40,000  times  in  his  corps  alone  without  a  single  death, 
and  he  attributed  the  result  largely  to  the  splendid  grade  of  chloroform  which 
the  Union  Army  had  supplied  him  (almost  all  the  chloroform  used  by  the  Con- 
federate Army  was  captured  from  the  Federals,  although  some  of  English  manu- 
facture came  through  a  blockade.) 

In  1882  Preston  [Pharm.  J.  (3),  12,  982]  recorded  that  there  had  occurred 
53  deaths  in  152,260  administrations,  and  that  in  these  53  cases  the  impure 
chloroform  had  something  to  do  with  the  fatal  results.     Atthill    (Brit.  Med.  J., 


288  ANESTHESIA 

DuBois-Eeymond  ^  appeared  to  have  experimentally  demonstrated 
that  impure  chloroform  is  dangerous.  Therefore,  to  the  rules  for  ad- 
ministering chloroform  so  often  given,  he  considered  that  one  omitted 
by  all  but  Sedillot  and  his  school  should  be  added,  namely,  that  the 
quality  of  the  chloroform  be  carefully  determined  and  only  the  very  best 
chloroform  procurable  be  employed  for  anesthesia. 

There  can  be  no  question  but  that  DuBois-Eeymond  obtained  re- 
sults which  indicated  rather  a  difference  of  degree  than  of  kind  be- 
tween the  action  of  pure  and  impure  anesthetic  chloroform.  He  insisted 
that  the  impurities  act  as  cardiac  depressants ;  ^  but,  as  was  noted  at 

1892,  i,  110)  stated  that  he  had  administered  chloroform  in  over  two  thousand 
cases,  and  considered  that  it  is  essential  for  its  safe  use  that  the  chloroform  be 
pure;  he  mentioned  that  the  chloroform  in  general  use  at  that  time  was  often 
impure. 

Chisholm  (Sci.  Am.  Suppl,  No.  642,  10,259),  who  had  in  1888  a  record  of 
10,000  cases  of  general  anesthesia  with  chloroform  and  no  deaths,  recorded  his 
experiences,  but  made  no  mention  whatsoever  of  the  purity  of  the  chloroform 
used. 

iBrit.  Med.  J.,   1892,  1,  209. 

2  The  report  of  the  Hyderabad  Commission  shows  that  deaths  from  chloro- 
form are  more  frequently  due  to  its  checking  the  power  of  respiration  than  to 
arrest  of  the  heart's  action;  see,  in  this  connection.  Lancet,  1890,  1,  149,  421, 
486,  1140,  1369;  1890,  ^,  356.  Indeed,  Lawrie  states  (Chloroform,  1901,  15) 
the  doctrine  that  chloroform  has  no  direct  action  on  the  heart  must  be  con- 
sidered as  finally  established.  This  is  supported  by  the  results  of  the  bio- 
chemical observations  of  Feigl  and  Meier  (BiocJiem.  Z.,  1906,  316),  who  con- 
cluded that  narcotic  doses  of  pure  chloroform  have  little  or  no  action  on  blood 
pressure,  the  heart,  or  the  circulatory  system  in  general;  and  that  these  effects, 
when  observed,  are  usually  due  to  accompanying  impurities  in  commercial  alco- 
hol. Some  observations,  however,  seem  to  indicate  that  chloroform  has  an  action 
on  the  circulatory  system,  although  in  these  cases  the  purity  of  the  anesthetic 
was  not  always  considered.  Cf.,  for  example,  Filehne  and  Biberfeld:  Z.  f. 
exper.  Path.  u.  Therap.,  1906,  3,  171;  these  investigators  discuss  the  advisability 
of  adding  volatile  analeptics  to  chloroform  to  prevent  the  reduction  of  blood 
pressure.  Also,  Busquet  and  Pachon  (Compt.  rend.  Soc.  iiol.,  66,  90)  reported 
fibrillation  of  guinea-pig's  heart  under  the  influence  of  chloroform;  Schaeffer 
and  Seharlieb  (Proc.  Physiol.  Soc,  1903,  17)  have  insisted  on  the  specific  nature 
of  the  action  of  chloroform  on  cardiac  muscles;  and  Embley  and  Martin  (J. 
Physiol.,  32,  147)  have  found  that  the  action  of  chloroform  in  the  blood  in  such 
quantities  as  may  occur  with  inhalation  of  1  to  3  per  cent  of  vapor  in  air  para- 
lyzes the  neuromuscular  mechanism  of  the  blood  vessels.  Tissot  {Compt.  rend., 
142,  234)  reported  that  more  than  70  mg.  of  chloroform  per  100  c.c.  of  arterial 
blood  often  causes  death.  It  appears  that  chloroform  forms  a  loose  combination 
with  hemoglobin;  for  a  discussion  of  the  physical  chemistry  of  anesthesia, 
wherein  this  is  discussed,  see  Moore  and  Eoaf:  Thompson,  Yates  and  Johnston 
Lai.  Bept.  Liverpool,  1905-6,   151-94. 

Waller  (Nature,  76,  403)  "tested  purified  chloroform  against  the  concen- 
trated residue  of  its  impurities,  and  found  the  former  to  be  more  powerful 
than  the  latter";   he  did  not,  however,  lay  any  stress  upon  the  fact  that   anes- 


CHLOROFORM  289 

the  time/  it  does  not  appear  that  by  their  removal  pure  anesth(?tic 
chloroform  ^  ceases  to  hamper  circulation."  That  the  impurities  are 
ordinarily  very  slight  DuBois-Eeymond  admitted,  but  he  contended  that, 
although  really  infinitesimal  in  quantity,  they  act  strongly  in  chloro- 
form solution.  From  his  experimental  investigations  and  deductions, 
we  learn  that  there  are  undoubted  impurities  which  are  able  to  intensify 
and  hasten  the  lethal  properties  of  chloroform,  but  we  cannot  definitely 
assert  Just  what  these  are.  We  know,  however,  what  the  general  likely 
impurities  of  anesthetic  chloroform  are;  and,  if  proper  precautions  are 
taken  to  guard  against  their  presence,  untoward  symptoms  should  not 
follow  the  proper  administration  of  anesthetic  chloroform. 

Stability  of  Chloroform. — There  has  been  not  a  little  variety  of 
opinion  among  chemists  as  to  the  nature  and  products  of  the  decom- 
position of  chloroform,  especially  the  changes  which  chloroform  under- 
goes upon  exposure  to  air ;  in  fact,  this  discordance  dates  from  the  intro- 
duction of  chloroform  as  an  anesthetic  and  prevails  to-day.  This  con- 
dition is  ascribable  to  the  many  influencing  factors  occasioned  by  the 
degree  of  purity  of  the  chloroform  which  may  have  been  under  ex- 
amination, the  extent  and  nature  of  its  exposure;  but  it  is  principally 
due  to  the  failure  to  consider,  and  therefrom  to  correctly  interpret,  the 
role  of  the  general  variable,  alcohol,  and  with  it  the  accompanying 
moisture. 

Decomposition  of  Pure  Chloroform. — The  products  of  the  decomposi- 
tion of  "pure"  chloroform,  according  to  various  investigators,  may  be 
thus  summarized : 

thetic  chloroform  can  be  of  variable  quality.  Tunnicliffe  (Pharm.  J.,  (4),  18, 
515)  subjected  samples  of  anesthetic  chloroform  to  mechanical  shaking  for  sev- 
eral days,  then  exposed  them  for  a  considerable  time  to  direct  July  sunlight,  and 
finally  allowed  them  to  evaporate  in  the  laboratory  to  one-half  bulk;  the  residual 
portion  did  not  differ  at  all  from  pure  chloroform  in  its  toxic  action  on  cardiac 
muscle. 

iBrit  Med.  J.,  1892,  1,  236. 

2  '  *  Chloroform  Pictet ' '   was  taken  as  the   example. 

^  See  (1)  supra,  and  also  Charteris  and  MacLennan:  Brit.  Med.  J.,  1892,  1, 
679,  who  believed  that  differently  manufactured  chloroform,  although  conform- 
ing to  the  tests  specified  by  the  British  Pharmacopoeia,  might  have  different  ac- 
tions, and  that  possibly  some  of  the  dangers  were  due  to  the  employment  of 
impure  chloroform — not  by  any  means  an  original  idea,  yet  one  unique,  coming 
as  it  did  as  the  expression  from  a  therapeutic  standpoint.  Therefore,  they 
tested  this  assumption  by  administering  six  different  makes  of  chloroform  to 
guinea-pigs  and  found  that  there  was  a  very  evident  difference  in  action  ex- 
hibited by  the  different  chloroforms,  five  of  which  were  of  standard  British  manu- 
facture. Thus,  with  ' '  chloroform  Pictet ' '  and  one  chloroform  prepared  from 
pure  ethyl  alcohol,  recovery  was  quicker  than  with  chloroform  from  rectified 
spirit,  and  three  other  makes  from  ethyl  alcohol,  and,  further,  during  recovery 
no  rhythmic  tremors  were  observed. 


290  ANESTHESIA 

Chlorin;  Hydrogen  chlorid Morson;  Maisch;  Hager. 

Carbonyl  chlorid Rump;  Regnault. 

Carbonyl  chlorid;  Hydrogen  chlorid.  .  .  .  Schoorl  and  Van  den  Berg;  Dott. 

Carbonyl  chlorid;  Chlorin Brown;  Schacht  and  Biltz;  Adrian. 

The  formation  of  carbonyl  chlorid  alone  has  been  definitely  agreed 
upon.  Free  chlorin  ^  can  only  result  from  the  photochemical  decom- 
position- of  carbonyl  chlorid:     CQCly"^~~CO-|-Cl.,. 

Tihe  decomposition  of  chloroform  has  been  universally  conceded  to 
be  an  oxidation  process.  The  extent  of  the  oxidation  is  dependent  upon 
the  nature  of  the  container,  the  amount  of  air  present,  the  purity  of 
the  sample,  and  the  intensity  of  the  light  to  which  it  is  exposed.^ 

It  is  likely  that,  in  the  cases  where  chlorin  has  been  identified  as 
an  indication  of  incipient  alteration  of  chloroform,  hydrogen  dioxid 
was  the  real  cause  of  the  reactions  observed. 

Role  of  Alcohol  in  Anesthetic  Chloroform. — With  regard  to  the 
changes  which  occur  in  anesthetic  chloroform,  that  is,  chloroform  con- 
taining alcohol,  during  exposure  to  air  and  light,  there  also  existed  a 
decided  diversity  of  opinion,^  principally  owing  to  the  fact  that  no 
examinations  were  made  during  the  course  of  the  various  investiga- 
tions, so  far  as  we  are  aware,  for  the  presence  of  the  oxidation  products 
of  alcohol  in  such  chloroform.  Some  have  even  regarded  the  presence 
of  absolute  alcohol  in  chloroform  as  deleterious.*  The  whole  subject 
^  Vide  Baskerville  and  Hamor:     J:  Ind.  Eng.  Chem.,  4,  No.  4. 

2  It  is  generally  accepted  that  chloroform  is  unaffected  by  light  alone,  and 
that  light,  although  it  accelerates  oxidation,  is  not  a  necessary  factor  in  the 
process.  However,  several  investigators  appear  to  have  inclined  to  the  view  that 
light  favors  decomposition.  In  this  connection,  see  Coehn  and  Decker:  Ber.  43, 
130;  and  Weigert:  Ann.  Fhysik,  1907  (4),  24,  55.  The  influence  of  light  on 
the  reversible  reaction,  CO+Cl,-^-^^ COCL,  seems  to  be  purely  catalytic.  The 
role  of  any  water  is  that  of  a  true  chemical  catalyst.  The  decomposition  of  pure 
chloroform  is  accelerated  by  light,  and  carbonyl  chlorid  is  formed  with  in- 
creased readiness  in  the  presence  of  acids.  Lowry  and  Magson  {Trans.  Chem. 
Soc,  93,  121)  observed  that  the  formation  of  carbonyl  chlorid  is  evidently 
accelerated  by  the  presence  of  acids. 

3  DuBois-Eeymond  (Sci.  Am.  Suppl,  No.  839,  13,  413)  considered  that  alcohol 
was  of  no  use  when  impurities  were  present  and  was  not  necessary  when  the  chloro- 
form was  pure;  and  Helbing  and  Passmore  {Helbing's  Pharm.  Record, 
March,  1892)  concluded  from  the  few  experiments  which  they  made  on  the  de- 
composing influence  of  sunlight  on  chloroform  in  the  presence  of  concentrated 
sulphuric  acid  that  the  value  of  the  addition  of  absolute  alcohol  to  pure  chlo- 
roform was  questionable.  These  investigators  assumed  that  the  chloroform  which 
they  termed  pure  contained  no  alcohol. 

i  Pharm.  J.,  7,  345.  Mialhe  found  that  chloroform  acquired  "caustic  proper- 
ties" when  mixed  with  a  small  quantity  of  absolute  alcohol,  and  concluded  that 
chloroform  used  in  medical  practice  which  caused  vesication  of  the  lips  and  nos- 
trils contained  a  certain  quantity  of  anhydrous  alcohol,  the  presence  of  which 
was  suspected  by  Soubeiran  and  Gerdy.  Mialhe  thought  that  the  alcohol  might 
act  by  combining  with  and  coagulating  the  albuminous  fluids  of  the  body. 


CHLOROFORM  291 

was  therefore  carefully  investigated  by  one  of  us  (C  B.)'  It  was  also 
hoped  to  throw  light  on,  if  not  fully  explain,  the  role  of  alcohol  ^  and 
other  substances  in  the  so-called  preservation  of  clilorofonn,  a  satisfac- 
tory explanation  of  which  had  been  wanting. 

Those  who  have  investigated  the  part  played  by  alcohol  in  preserv- 
ing chloroform,  up  to  the  present  time  have  held  that  either  chloroform 
decomposes  in  the  presence  of  alcohol  and  that  alcohol  takes  care  of 
the  decomposition  products,  or  that  the  alcohol  acts  as  a  "catalytic  re- 
tarding agent"  (Stadlmayr). 

We  have  definitely  shown  that  the  products  of  the  oxidation  of  anes- 
thetic chloroform  are  primarily  the  oxidation  products  of  alcohol,  and 
that  no  decomposition  of  chloroform  itself  occurs  while  the  oxidation 
of  alcohol  proceeds.  When  the  oxidation  of  alcohol  reaches  a  maximum, 
decomposition  of  the  chloroform  goes  on,  as  in  the  case  of  pure  chloro- 
form, with  the  exception  that  chlorinated  derivatives  of  the  oxidation 
products  of  alcohol  may  result.  The  decomposition  of  the  chloroform 
itself  is  retarded,  even  prevented,  so  long  as  oxidation  of  the  alcohol 
proceeds,  and  the  retardation  is  consequently  dependent  upon  the 
amount  of  alcohol  present.  The  preservative  action  of  alcohol,  first  sug- 
gested by  Squibb  in  1857  and  later  (1863)  by  Brown,  independently,  is 
essentially  that  of  a  "shunt,"  and  any  substance  soluble  in  chloroform 
and  readily  oxidizable  will  exert  an  inhibitory  effect  on  the  oxidation  of 
chloroform  itself;  for  example,  sulphur  and  many   other  substances.^ 

1  Loc.  cit. 

2  The  amounts  of  alcohol  stated  as  permissible  in  the  various  official  chloro- 
forms intended  for  anesthetic  purposes  are  as  follows: 

Belgium     1.0  per  cent. 

Denmark      1.0  per  cent. 

Sweden     0.5—1.0  per  cent. 

United    States    0.6 — 1.0  per  cent. 

France      0.005  part  by  weight. 

Italy     0.5  per  cent. 

Switzerland      1.0  per  cent  absolute. 

3  "Inorganic  Preservatives."  Boettger  (Bull,  de  therap.,  May  15,  1864) 
found  that  chloroform  which  had  undergone  decomposition  by  exposure  to  sun- 
light might  be  purified  by  agitation  with  sodium  hydroxid,  and  stated  that  when 
chloroform  was  placed  in  contact  with  sodium  hydroxid  it  might  be  preserved 
indefinitely.  Newman  and  Eamsay  (Lancet,  Jan.  23,  1897)  recommended  a  simi- 
lar treatment,  namely,  the  use  of  lime,  both  for  purification  of  decomposed 
chloroform  and  as  a  preservative.  Brown  (Pharm.  J.,  61,  669;  Mon.  Sci.,  53, 
423),  however,  found  that  the  method  of  Newman  and  Eamsay  was  unsatisfac- 
tory. These  compounds  act  by  combining  with  the  decomposition  products  of 
chloroform.     They  do   not   prevent   decomposition. 

Allain  (Chem.  Ztg.,  19,  310)  learned  that  sulphur,  purified  by  digesting  for 
24  hours  with  ammonia,  and  then  carefully  washed  and  dried,  would  effectually 
prevent  the  decomposition  of  chloroform.  (In  a  sample  saturated  with  sulphur, 
after  exposure  to  sunlight  for  four  months,  no  impurities  could  be  detected  and 


292  ANESTHESIA 

All  compounds  which  have  been  found  to  serve  as  preservatives  of  chlo- 
roform are  reducing  agents,  and  the  effect  is  only  due  to  their  capacity 
for  oxidation. 

Character  of  Containers. — Anesthetic  chloroform  should  preferably 
be    furnished   in    vials,    ampules,    or   bottles    of    high-grade    anactinic 

the  sample  produced  a  "normal  anesthesia").  Temoin  (Pharm.  central.,  45, 
872;  Chem.  and  Drug.,  64,  973)  reported  that  chloroform  to  which  0.4  per  cent 
of  sulphur  had  been  added  underwent  no  alteration  on  keeping,  even  when  ex- 
posed to  light.  This  was  verified  by  Dott  [Fharm.  J.,  (4),  2,  249],  who  also 
experimented  successfully  with  morphin,  gallotannic  acid,  and  hypophosphorus 
acid. 

"Organic  Preservatives."  Masson  [J.  pharm.  chim.,  (6)  9,  568]  found  that 
poppy-seed  oil  exerted  a  marked  preservative  action  on  chloroform.  A  specimen 
containing  0.1  per  cent  was  exposed  to  direct  sunlight  for  21  days,  at  the  end 
of  which  time  there  was  no  decomposition;  and  one  with  0.2  per  cent  of  the 
oil,  kept  in  ordinary  light,  showed  no  decomposition  in  three  years.  From 
Masson 's  own  observations  on  the  preservative  powers  of  alcohol  (Masson  con- 
sidered that  the  preservative  action  of  alcohol  on  chloroform  was  demonstrated 
by  the  condition  of  the  samples  at  the  Pharmacie  Central,  in  1899,  where  speci- 
mens containing  only  0.1  per  cent  and  exposed  in  yellow  glass  bottles  in  a  win- 
dow to  diffused  light  were  found  to  have  kept  perfectly  after  standing  for  ten 
years),   one  would  conclude  that  he  considered  it  perfectly  satisfactory, 

Breteau  ("French  Patent,"  1905,  353,  858)  devised  a  method  for  the  pre- 
vention of  the  alteration  of  chloroform  in  the  air  and  light,  and  of  indicating 
finally  the  decomposition,  which  consisted  in  adding  to  the  chloroform  from  5  to 
10  thousandths  parts  of  one  of  the  following  bodies:  pith  of  elder,  cork  of 
coniferse;  and  3  to  5  thousandthss  parts  of  guaiacol,  ionone,  spermaceti,  choles- 
terol, terpineol,  citronellic  acid,  geranic  acid,  etc.  He  stated  that  the  elder  pith 
might  be  impregnated  with  a  solution  of  a  material  colorless  in  chloroform,  and 
dry,  this  material,  as  Congo  red,  undergoing  a  change  of  tint  under  the  influence 
of  the  decomposition  products  of  chloroform.  Congo  red  was  stated  to  be  very 
desirable,  since  it  turned  blue,  and  gradually  decomposed,  when  the  alteration 
was  decided.  Later  Breteau  mentioned  the  following  substances  as  preservatives 
of  chloroform  in  addition  to  those  previously  mentioned:  ethyl  alcohol  and  ethyl 
ether,  nitrobenzene,  methyl  and  amyl  salicylates,  thymol,  and  coniferin.  As 
indicators,  he  stated  that  cellulin  and  gelatin  might  be  used  in  addition  to 
dyestuflfs  and  that  the  indicator  might  also  consist  of  a  dyestuff  which  changed 
color  in  the  presence  of  the  decomposition  products  of  chloroform  ("First  Addi- 
tion to  French  Patent,"  353,  858,  1905,  dated  June  30,  1905).  Still  later  he 
stated  that  the  indicator  might  be  interposed  between  the  chloroform  and  the 
stopper  of  the  container,  or  might  be  fixed  to  the  stopper,  or  might  even  form 
the  stopper.  Cinnamic  acid  and  inosite-mono-methyl  ether  were  added  to  the 
list  of  preservative  agents  ("Second  Addition  to  French  Patent,"  dated  Nov. 
18,  1905,  358,  858). 

Breteau  and  Woog  (Compt.  rend.,  143,  1193)  found  that,  by  the  use  of  2  to 
4  parts  per  1,000  of  oil  of  turpentine,  purified  spermaceti,  menthol,  terpineol, 
citronellol,  geraniol,  amyl  and  methyl  salicylates,  guaiacol,  thymol,  safrol,  ionone, 
or  methyl-protocatechuic  aldehyd,  chloroform  could  be  preserved  in  white  glass 
bottles  in  diffused  light.  A  number  of  indicators  show  the  acidity  of  chloroform 
undergoing  incipient  decomposition  before  it  is  sufficiently  developed  to  affect 
silver  nitrate. 


CHLOROFORM  293 

glass/  containing  about  the  quantity  sufficient  for  one  narcosis,  and  at 
the  most  not  more  than  can  be  used  within  several  days.  If,  for  any 
particular  reason,  chloroform  is  ordered  in  a  large  container,  it  is  ad- 
visable, immediately  after  opening  it,  to  subdivide  the  entire  remain- 
ing contents  into  two-ounce  bottles,  taking  care  to  fill  the  small  bottles 
completely.  In  no  case  should  chloroform  be  gradually  withdrawn  in 
small  quantities  from  large  bottles  or  carboys.  When  it  is  found  neces- 
sary to  store  anesthetic  chloroform  it  should  always  be  kept  in  a  cool, 
dark  place,  in  well-filled,  or,  better  still,  completely  filled,  tightly  stop- 
pered bottles  of  anactinic  glass. 

The  keeping  qualities  of  anesthetic  chloroform  may  be  seriously 
affected  by  the  character  of  containers.  The  question  of  keeping  anes- 
thetic chloroform  in  tin  containers  has  been  much  agitated  in 
the  United  States  War  Department,  and  within  the  last  ten  years  this 
department  has  decided  in  favor  of  the  tin  container.  We  (C.  B.)  be- 
lieve that  glass  containers  are  more  conducive  to  the  maintenance  of 
purity  for  several  reasons.  First,  in  cleaning  the  vessels  before  filling, 
any  foreign  matters  present  may  be  readily  observed  and  the  bottles 
properly  cleaned.  Second,  in  the  case  of  tins,  some  of  the  flux  used  in 
soldering  may  be  introduced  and  thus  impart  an  acid  reaction  to  the 
chloroform.  Hydrochloric  acid  accelerates  the  decomposition  of  chloro- 
form. The  introduction  of  this  flux  is  also  a  problem  in  ether  manu- 
facture which  requires  the  utmost  care.  Third,  we  have  been  informed  ^ 
that  "moist  chloroform  in  the  pr^seilcl  of  a  metal  will  slowly  form 
traces  of  CHaCL  and  probably  .  .  .  that  it  is  possible  to  distill  pure, 
dry  chloroform  in  a  metal  container  and  produce  a  decomposition,  as 
Shown  by  the  following  formula : 

4CHCI3  +  Cuo  =  C^Cle  +   2CH2CI,  +  CU2CI2. 

This  reaction,  however,  takes  place  so  slowly  that  it  would  never  be 
noticed  except  in  the  handling  of  a  material  on  which  superlative  efforts 
have  been  expended  for  years  in  order  to  get  the  last  extreme  of  purity." 
Moreover,  "all  chloroform  contains  traces  of  CHoClg." 

Stoppers  for  the  Containers. — The  Pharmacopeia  of  the  United 
States  formerly  required  the  use  of  glass-stoppered  bottles,^  but  subse- 

^  The  glass  should  show  no  alkaline  reaction  when  the  bottle  is  filled  with  dis- 
tilled water  containing  several  drops  of  plienolphthalein  solution  and  heated  at 
100°  C.  for  six  hours.  On  the  action  of  alkalies  on  chloroform,  see  Berthelot, 
Bull.  Soc.  chim.,  (2),  ^9,  4;  Andre,  Compt.  rend.,  102,  553;  de  St.  Martin,  ihid., 
106,  492;  and  Mossier,  Monatsli.,  29,  573.  It  appears  to  be  well  established  that 
potassium  hydroxid  in  alcoholic  solution  will  slowly   decompose  chloroform. 

2  By  a  prominent  manufacturer  in   a  private  communication. 

3  All   of   the    manufacturers   of   chloroform   in    this    country   use    brown   glass  , 
("anactinic")   bottles.     Of  the  eight  different  makes  of  German  chloroform  that 
have  come  into  our  hands,  only  two   were  contained  in  colorless  bottles. 


294  ANESTHESIA 

quently  changed  this  to  well-stoppered  bottles,  thus  allowing  the  use  of 
cork  stoppers,  a  practice  which  has  become  general  in  this  country.^ 

Two  objections  have  been  urged  against  the  employment  of  cork 
stoppers : 

First,  the  chloroform  penetrates  the  cork  after  some  time,  especially 
during  the  agitation  incidental  to  shipment,  causing  shrinkage  and  per- 
haps leakage.^  The  second  objection  is  that  organic  matter  is  ex- 
tracted from  the  cork,  and  the  chloroform  fails  when  the  sulphuric 
acid  test,  a  test  used  for  the  detection  of  fusel  oil,  chlorinated  decom- 
position products,  etc.,  is  applied.  To  obviate  these  difficulties  cer- 
tain manufacturers  of  chloroform  have  adopted  the  plan  of  covering 
the  bottom  of  corks  with  tin  foil,  a  procedure  which  so  far  has  been 
found  to  be  satisfactory,  but  which  may  be  open  to  some  of  the  objec- 
tions to  tin  containers.  Other  manufacturers  use  a  paper  or, parchment 
covering,  and  still  others  select  only  the  best  corks  and  extract  them 
thoroughly  with  chloroform  before  use. 

The  Changes  Which  Anesthetic  Chloroform  Undergoes  When  a  Cur- 
rent of  Oxygen  Is  Conducted  Through  It. — Among  the  anesthetic  mix- 
tures the  combination  of  chloroform  vapor  with  oxygen  was  used  shortly 
after  the  introduction  of  chloroform  as  an  anesthetic,  and  it  has  re- 
cently been  reintroduced  into  practice  by  Neiidorfer,  Kreutzmann,  and 
others.  It  is  stated  by  anesthetists  that  oxygen  does  not  antagonize  the 
action  of  chloroform  on  the  heart  or  nerve  centers,  but  that  it  protects 
the  patient  from  the  dangers  which  result  when  chloroform  is  admin- 
istered while  his  blood  is  in  a  condition  of  undue  venosity  ^  and  that  it 
prevents  any  intercurrent  asphyxial  condition.  Gwathmey  has  stated 
positively  *  that  oxygen  increases  the  value  of  all  inhalation  anesthetics 
as  regards  life.^ 

1  In  Germany,  however,  glass-stoppered  bottles  are  used  by  prominent  pro- 
ducers of  anesthetic  chloroform. 

2  Allain  [J.  pharm.  chim.  (3),  9,  571]  and  Masson  [ibid.,  (6),  9,  568]  have 
recommended  that,  when  chloroform  is  kept  in  cork-stoppered  bottles,  a  lute  of 
"bichromate  gelatin"  should  be  used  to  prevent  leakage.  This  is  unnecessary 
when  a  proper  stopper  is  used,  and  the  employment  of  lutings  on  the  stoppers 
has  led  to  differences  between  the  manufacturer  and  consumer  in  the  past. 

3  Buxton:      "Anaesthetics,"  4th   ed.,   299. 

^  Med.  Eec,  Oct.  8,  1910,  616.  On  chloroform-oxj'gen  narcosis,  see  also  Zieg- 
ner:    Milnch.  med.  Wocli.,  57,  2585. 

^  It  has  been  maintained,  however,  that  chloroform  undergoes  alteration  in 
this  procedure.  Falk  (Deut.  med.  Woch.,  1902,  862)  attempted  to  demonstrate 
that  the  passage  of  oxygen  through  chloroform  (the  purity  of  this  was  not  de- 
scribed, but  it  was  evidently  of  the  grade  specified  by  the  German  Pharma- 
copoeia) produces  chemical  changes  in  the  anesthetic.  He  reported  that,  after 
the  passage  of  oxygen  for  20  minutes,  changes  could  be  recognized  in  the  resi- 
dual chloroform,  in  some  cases  hydrochloric  acid  and  in  others  an  acid  having  re- 
ducing properties  (acetic  acid,  resulting  from  the  oxidation  of  the  alcohol  in 
the   chloroform   used?)    having   been   recognized.      The   quantities   produced   were 


CHLOROFORM  295 

We  have  investigated  the  changes  which  anesthetic  chloroform  under- 
goes when  a  current  of  oxygen  is  conducted  through  it.  Wc  have  found 
that  no  serious  oxidation  occurs  during  the  period  of  anesthesia,  and 
that  the  oxidation  which  does  occur  has  to  do  only  with  the  alcohol  pres- 
ent. Furthermore,  it  was  determined  that  the  oxidation  products  were 
entirely  removed  when  the  chloroform  vapor  was  swept  hy  the  oxygen  cur- 
rent through  water.^ 

The  Decomposition  of  Chloroform  Vapor  TJpon  Exposure  to  Gas 
Light,  Etc.,  During  Administration. — The  occurrence  of  untoward  symp- 
toms during  the  administration  of  chloroform  in  rooms  in  which  gas  is 
burning,^  or  where  there  are  other  varieties  of  naked  flames,"  or  strong 
electric  light  *  has  been  reported ;  consequently  authorities  have  warned 

found  to  be  greater  the  higher  the  temperature  and  degree  of  illumination. 
This  work  is  partially  contradicted  by  the  clinical  results  obtained  by  anesthetists, 
and  by  the  observations  of  Willcox  and  Collingwood  (Brit.  Med.  J.,  Nov.  5,  1910) 
on  the  administration  of  oxygen  bubbled  through  absolute  alcohol.  They  stated 
that  the  administration  of  oxygen  bubbled  through  absolute  alcohol  is  a  marked 
cardiac  stimulant.  It  is  especially  important  to  note  that  they  found  the  admin- 
istration pleasant  and  non-irritating  to  the  patient — that  it  caused  no  ill-effects  to 
the  lungs  or  bodily  system. 

1  Baskerville  and  Hamor,  loc.  cit.  Anesthetic  chloroforms  containing  0.56  to 
1.00  per  cent  of  alcohol  and  0.03  to  0.05  per  cent  of  water  were  used.  Oxygen 
was  allowed  to  flow  through  314  to  4  ounces  of  chloroform  in  the  Gwathmey 
apparatus  at  such  rates  that  about  half  remained  in  the  vaporizer  after  3%  to 
10%  hours.  The  vapors  were  cooled  by  a  suitable  condenser  and  collected.  The 
examination  of  the  residue  and  condensed  chloroform  showed  the  following: 

Acidity  (acetic  acid)  : 

Chloroform    used     None. 

Residue  in  container 0.00015  gm.  in  100  c.c. 

Condensed  chloroform None. 

Sulphuric  acid  test: 

Chloroform  used   Negative. 

Residue  in  container Marked  reaction. 

Condensed  chloroform   Negative. 

2  One  of  the  earliest  references  to  the  decomposition  of  chloroform  by  exposed 
flames  is  in  the  China  Med.  Missionary  J.,  Dec,  1888,  160.  Iterson,  Fischer, 
and  Zweifel  drew  attention  to  this  decomposition  in  1889,  and  in  that  year  Pat- 
terson narrated  personal  experiences  (Practitioner,  42,  418).  See  also  Lancet, 
March  12,  1898;  Birmingham  Med.  Rev.,  Aug.,  1892;  but  especially,  Schumburg, 
Apoth,  Ztg.,  13,  758;  Gerlinger,  ibid.,  17,  314;  and  Bisenlohr  and  Fermi,  Ber., 
1892,  585.  Soubeiran  and  Liebig  had  observed  that  a  mixture  of  chloroform  and 
alcohol  in  equal  measures  burns  with  a  smoky  flame  and  pungent  odor. 

According  to  Ramsay  and  Young  (Jahresber.,  1886,  628),  the  vapor  of  chloro- 
form, when  passed  through  a  red-hot  tube,  yields  hexachlor-benzene,  perchlor- 
ethane,  and  some  perchlorethylene. 

3  Oil  lamps  and  candles.     Waddelow,  Pharm.  J.   (4),  6,  324. 

*  Buxton  (''Anaesthetics,"  1907,  180)  states  that  he  observed  that  chloroform 
decomposes  when  a  powerful  electric  lamp  is  held  over  the  Inhaler.  Cf.  Schoorl 
and  Van  den  Berg  (Pharm.  Weelcblad,  do,  47),  who  show  that  air  is  necessary 
for  such  decomposition. 


296  ANESTHESIA 

against  the  performance  of  surgical  operations  by  gas  light. ^  As  to  just 
what  products  are  formed  there  is  a  difference  of  opinion.  Iterson  ^ 
considered  that  there  occurred  a  combination  of  the  chloroform  vapor 
with  the,  combustion  gases,  whereas  Hartman  ^  and  Waddelow  *  ob- 
served an  odor  of  chlorin.  Von  Langenbeck  considered  that  chloro- 
carbonic  acid  was  formed,  and  Breaudat  found  hydrochloric  acid  and 
an  acrid  oil. 

At  all  events,  when  a  mixture  of  chloroform  vapor  and  air  is  decom- 
posed by  a  flame,  irritating  compounds  are  formed.^ 

Effect  of  Agitation  Upon  Anesthetic  Chloroform. — Tunnicliffe  con- 
cluded that  when  chloroform  is  initially  pure,  except  for  added  alcohol, 
it  remains  free  from  pharmacological  deterioration  under  the  ordinary 
conditions  of  military  transport,  providing  that  the  bottles  are  kept 
closely  stoppered  and  protected  from  strong  light.  Baskerville  sub- 
jected several  samples  of  chloroform  to  intermittent  agitation  for  over 
two  hundred  hours  in  a  Spiegelberg  shaking  apparatus  and  learned 
that : 

(1)  When  anesthetic  chloroform  is  subjected  to  agitation  accom- 
panied by  shock,  the  alcohol  present  undergoes  oxidation,  the  extent  of 
this  being  dependent  upon  the  amount  of  air  present,  the  nature  of  the 
agitation,  especially  its  violence  and  length,  and  the  light  exposure. 
The  experiments  were  all  made  in  daylight  at  about  20°  C. 

(2)  Impurities  decomposable  by  sulphuric  acid  are  formed  under 
such  conditions,  these  resulting  both  from  oxidation  of  the  alcohol  and, 
when  unprotected  cork  stoppers  are  used,  from  the  extraction  of  or- 
ganic matter  from  the  stopper  or  luting.  "Chlorinated  decomposition 
compounds"  may  form,  although  we  are  inclined  to  attribute  the  re- 
sponse had  for  their  presence  to  oxidation  products  of  alcohol  in  this 
case. 

Since  these  conclusions  apply  to  anesthetic  chloroform  of  the  present 
United  States  Pharmacopana  degree  of  purity  and  strength,  care  should 
be  exercised  to  see,  when  such  chloroform  is  shipped  for  considerable  dis- 
tances, or  is  to  be  kept  in  stock  on  shipboard,  that  a  minimum  amount 
of  air  is  present. 

Standards  of  Purity  for  Anesthetic  Chloroform. — There  have  been 
instances  of  sophistication  of  anesthetic  chloroform,*^  and  these,  while 

1  E.  g.  Von  Langenbeck:    Pharm.  Ztg.,  April  6,  1889,  221. 

2  Ibid. 

3  Ibid. 

*  Loc.  cit.     See  also  Wardleworth,  Pharm.  J,    (4),  14,   376. 

5  Lancet,  1899,  1,  1728;  Therap.  Gas.,  1899,  601;  Breaudat 's  "Diet,  de  physi- 
ologie. "     Cf.  Ragsky,   J.  prakt.  Chem.,  46,  170. 

6  Baird  (Proc.  Mass.  Pharm.  Assn.,  1906,  59)  examined  six  samples  of  chloro- 
form in  1904  and  found  one  adulterated. 


CHLOROFORM  297 

rare,  have  been  cases  mainly  of  substitution  of  commercial  chloroform.^ 
The  purity  of  the  drug  may  be  endangered  through  lack  of  chemical 
control  in  the  manufacture  or  from  careless  storage.  It  is  quite  evident 
that  every  sample  cannot  be  tested.  Eeliance  must  be  placed  upon  the 
integrity  of  the  manufacturers.  Confidence  in  the  product,  however, 
may  be  enhanced  by  chemical  examinations  of  shipments  from  time 
to  time.  Manufacturers  and  users  will  find  that  compliance  with  the 
tests  given  in  Appendix  II  will  insure  a  drug  suitable  for  anesthesia. 


SPECIAL   PHYSIOLOGY 

The  difficulties  encountered  in  the  study  of  the  effects  of  chloroform 
upon  the  organism  have  been  attributed  by  Gill  ^  to  the  isolation  of  the 
phenomena  of  the  physiological  action  of  this  agent — in  other  words, 
to  "the  arbitrary  separation  of  prominent  phenomena  from  their  inti- 
mate surroundings."  Conclusions  should  not  be  drawn  from  an  indi- 
vidual phenomenon,  but  from  a  set  of  phenomena,  or  a  "state."  Gill 
cites,  as  an  illustration,  the  phenomenon  of  pallor,  which  is  a  direct 
manifestation  of  reflex  stimulation  of  the  vasomotor  center.  It  is 
also  a  direct  result  of  primary  cardiac  syncope,  and,  again,  it  is  a 
secondary  result  of  stomachic  inhibition  of  the  respiratory  center.  The 
fallacy  of  drawing  conclusions  from  pallor  alone,  without  the  aid  of  the 
accompanying  phenomena,  is  obvious. 

In  considering  the  special  physiology  of  chloroform,  as  well  as  of 
the  other  inhalation  agents,  for  purposes  of  convenience  the  phenomena 
have  been  grouped  according  to  the  part  of  the  organism  chiefly  in- 
volved. It  is  to  be  borne  in  mind,  however,  that  the  effects  of  chloro- 
form upon  one  system  of  organs  cannot  be  entirely  dissociated  from 
its  effects  upon  other  systems,  and  that  a  given  result  may  be  produced 
by  different  causes,  or  by  a  combination  of  causes. 

Inasmuch  as  the  physiological  action  of  inhalation  anesthetics  in 
general  is  based  largely  upon  observations  made  concerning  the  effects 

1  This  appears  to  have  been  practiced  as  late  as  1885  in  this  country,  since 
Davenport  [Am.  J.  Pharm.,  (4),  16,  111]  reported  that  fourteen  out  of  fifteen 
samples  of  chloroform  examined  by  him  in  that  year  were  the  crude  article. 
Chloroform  of  inferior  grade,  frequently  encountered  about  1880  [see  Perrin: 
Pharm.  J.,  (3),  9,  614;  and  Championniere,  ibid.,  (3),  12,  623],  especially  in 
France,  is  now  rarely  represented  as  being  of  anesthetic  grade.  This  is  largely 
due  to  the  stringency  of  many  of  the  pharmacopoeias,  but  is  in  part  to  be  ascribed 
to  the  experience  and  integrity  of  the  manufacturers.  It  sometimes  happens, 
however,  that  chloroform  is  declared  to  be  impure  by  surgeons,  following  a  fa- 
tality from  its  use  in  particular,  when  this  is  not  the  case.  For  an  example,  see 
the  experiences  of  Blum:   Pharm.  J.,   (4),  19,  103. 

2  Gill,   Richard:      "CHCl.    Problem,"   1906,   2. 


298  ANESTHESIA 

of  chloroform,  the  discussion  of  the  special  physiology  of  this  agent  may 
entail  a  certain  amount  of  repetition. 

Effects  Upon  the  Respiratory  System. — The  effects  of  chloroform 
upon  the  .respiratory  system  are  secondary  to,  and  largely  dependent 
upon,  the  effects  of  this  agent  upon  the  circulation,  low  arterial  tension 
being  a  very  important  factor.  The  respiratory  system,  even  to  the 
extent  of  complete  cessation  of  breathing,  is  also  affected  through  the 
action  of  chloroform  upon  the  nervous  mechanism  of  respiration. 

When  concentrated  chloroform  vapor  is  administered,  asphyxial 
symptoms  immediately  appear,  free  breathing  being  suspended  from 
reflex  closure  of  the  larynx.  With  a  low  percentage  of  chloroform, 
according  to  the  experiments  of  Collingswood  and  Buswell,^  chloroform 
quickly  produces  apnea  of  a  pronounced  character.  This  is  not  due 
to  diminution  of  carbon  dioxid  in  the  blood,  for  it  can  be  produced 
by  chloroform  mixed  with  expired  air.  Chloroform  diminishes  the  ex- 
citability of  the  respiratory  center  to  the  carbon  dioxid  stimulus. 

Buckmaster  and  Gardner  ^  have  given  a  number  of  plethysmographic 
tracings  to  show  the  lung  ventilation  during  chloroform  anesthesia  with 
different  percentages  of  chloroform  and  ether,  and  also  analyses  of  the 
blood  gases.  They  show  that  with  unimpeded  respiration  under  anes- 
thesia by  chloroform  given  at  a  slight  positive  pressure,  the  ventilation 
of  the  lung  takes  place  at  a  lowered  level.  During  a  narcosis  in  which 
respiration  continues,  the  lung  ventilation  is  diminished  in  the  first 
three  minutes  by  about  sixty  per  cent  of  its  original  value,  and  by  a 
similar  amount  after  prolonged  anesthesia.  They  consider  that  the 
carbon  dioxid  content  of  the  blood  is  reduced  below  a  threshold  value 
by  any  state  of  hyperpnea  prior  to  administration  of  the  drug,  and  this 
diminution  in  carbon  dioxid  content  plus  the  diminished  excitability 
of  the  respiratory  center  would  suffice  to  retard  or  abolish  the  activity  of 
the  center.  Gas  analyses  actually  show  that  with  a  deep  and  rapid 
respiration  there  is  a  marked  fall  in  the  carbon  dioxid  content  of  the 
blood.  They  also  bring  forward  evidence  to  show  that  the  diminution 
in  oxygen  content  of  the  blood  during  chloroform  narcosis  is  not  due 
entirely  to  diminished  alveolar  ventilation,  but  to  the  action  of  the  drug 
on  the  red  corpuscles.  For  further  effects  of  chloroform  upon  the 
respiratory  system  see  Stages  of  Anesthesia,  p.  306. 

Effects  Upon  the  Circulatory  System. — The  effects  of  chloroform 
upon  the  circulatory  system  have  been  made  the  subject  of  extensive 
investigation,  from  both  the  experimental  and  the  clinical  points  of 
view. 

The  action  of  chloroform  upon  the  Mood,  when  administered  by  in- 
halation, has  engaged  the  attention  of  a  number  of  investigators.     It  is 

'  Collingswood  and  Buswell,  Proc.  Physiol.  Soc,  1907,  34. 

="  Buckmaster  and  Gardner,  London  Boy.  Soc,  Nov.  16,  1911;  Nature,  88,  131. 


CHLOROFORM  299 

conceded  to  have  a  practical  bearing  upon  the  administration  of  this 
agent. 

Gill/  in  discussing  the  relation  between  chloroform  and  the  blood, 
emphasizes  the  point  that  this  relationship  is  twofold.  The  negative 
action  of  the  chloroform  causes  deoxygenation  by  diminishing  the  nor- 
mal supply  of  air  to  the  alveoli;  its  physiological,  or  physicochemical, 
action  is  indirectly  the  cause  of  the  suspension  of  the  functions  of  the 
cerebral  centers.  The  quantity  of  chloroform  vapor  that  is  absorbed 
may,  therefore,  be  limited  to  the  amount  of  oxygen  requisite  to  be 
abstracted  fr^m  the  blood.  Inasmuch,  however,  as  the  blood,  which  is 
directly  affected  by  the  physiological  action  of  chloroform,  is  a  variant, 
and  as  its  actual  condition  necessarily  influences  the  result  that  appears 
in  it,  it  follows,  as  Gill  contends,  that  each  individual  example  re- 
quires its  own  anesthetic  degree  of  chloroform  action.  Any  undue  inter- 
ference with  the  proper  function  of  the  respiratory  apparatus  tends, 
by  increasing  the  deoxygenation  of  the  blood,  to  intensify  the  action  of 
chloroform. 

According  to  Carlson,^  the  osmotic  concentration  of  the  blood  is  in- 
creased during  chloroform  anesthesia  in  proportion  to  the  depth  and 
duration  of  the  anesthesia.  This  is  probably  due  chiefly  to  the  amount 
of  the  anesthetic  dissolved  in  the  serum. 

The  action  of  chloroform  on  the  reducing  power  of  the  blood  has 
been  studied  by  Lambert  and  Garneier.^  When  defibrinated  blood  is 
treated  with  a  current  of  air  containing  chloroform  vapor,  the  reducing 
power  of  the  blood  is  sometimes  increased  at  once,  always  after  an 
hour,  and  this  increased  reducing  power  is  not  due  to  the  dissolution  of 
chloroform  in  the  blood.  When,  however,  defibrinated  blood  and  similar 
blood  containing  chloroform  are  made  to  circulate  respectively  through 
the  two  lobes  of  a  fresh  liver,  the  glycogen  disappears  more  rapidly  in 
the  lobe  through  which  the  blood  containing  chloroform  circulates,  and 
at  the  same  time  the  reducing  power  of  this  blood  increases  more  rap- 
idly than  that  of  pure  blood,  and  in  a  higher  degree  than  corresponds 
with  the  glycogen  that  disappears.  It  follows,  therefore,  that  the  in- 
creased reducing  power  is  not  due  simply  to  a  more  active  formation 
of  sugar  or  to  a  diminution  in  its  rate  of  consumption. 

Tunnicliffe  and  Eosenheim^  studied  the  action  of  chloroform  on 
the  heart  by  adding  saline  fluid  perfused  through  the  heart  by  Locke's 
method.  The  depressing  action  on  the  heart  produced  by  chloroform 
was  found  to  be  very  marked.  It  was  delayed,  however,  when,  in  addi- 
tion to  the  saline  fluid,  lecithin  was  added.    The  quantity  of  chloroform 

iGill:     Loc.  cit.,  254. 

2  Carlson:     Am.  J.  Physiol,  21,  161. 

3  Lambert  and  Garneier :      Compt.  rend.,  132,  493. 
4Tunnicliife  and  Rosenheim:      Proc.  Physiol.  Soc,   1903,    15. 


300  ANESTHESIA 

which  seriously  affected  the  heart  was  practically  identical  with  that 
in  the  blood  in  fully  narcotized  animals. 

Schaefer  and  Scharlieb  ^  have  insisted  on  the  specific  nature  of  the 
action  of  chloroform  on  cardiac  muscles.  The  state  of  the  heart  called 
paralytic  dilatation  is  regarded  by  them  as  one  of  excitatory  inhibition ; 
excitation  of  the  terminal  inhibitory  mechanism  is,  however,  distin- 
guished from  excitation  of  the  vagus  and  its  endings,  and  can  be 
brought  about  by  chloroform  when  the  vagus  endings  are  thrown  out  of 
action  by  atropin.  The  high  development  of  the  inhibitory  mechan- 
ism in  the  heart  explains  why  it,  of  all  muscular  tissues,  should  be 
most  profoundly  affected. 

It  is  of  special  interest  to  note  that  in  the  frog  chloroform  produces 
contraction  of  the  blood  vessels,  and  not  dilatation,  as  most  observers 
have  stated.  In  the  frog  used,  the  central  nervous  system  was  destroyed, 
either  entirely  or  with  the  exception  of  the  cerebrum. 

The  action  of  chloroform  on  the  blood  vessels  has  been .  studied  by 
Embley  and  Martin  ^  with  reference  to  the  kidneys  and  bowels.  They 
found  that  chloroform,  in  the  blood  in  such  quantities  as  may  occur 
with  the  inhalation  of  one  to  three  per  cent  of  the  vapor  in  the  air, 
paralyzes  the  neuromuscular  mechanism  of  the  blood  vessels.  This 
partly,  at  least,  accounts  for  the  fall  of  blood  pressure  which  results. 
These  findings  are  not  contradictory  to  those  of  Schaefer  and  Scharlieb, 
but  rather  supplement  them.^  Vessels  in  different  parts  may  react  in  dif- 
ferent ways  to  the  same  poison  in  different  doses.  The  dilatation  is 
mainly  confined  to  the  splanchnic  area. 

It  is  now  generally  conceded  by  clinical  observers  that  a  dilatation 
of  the  entire  cardiovascular  system  follows  the  inhalation  of  chloro- 
form.    The  fall  of  blood  pressure  is  thus  accounted  for. 

Tissot  *  has  studied  the  proportion  of  chloroform  in  the  organism 
during  anesthesia.  In  animals  rapidly  anesthetized  by  chloroform 
the  amount  present  in  the  blood  may  exceed  50  mg.  per  100  c.c,  and 
may  reach  70-80  mg.  If  the  anesthesia  is  slowly  induced,  it  sinks  to 
45  or  even  35  mg.  More  than  70  mg.  per  100  c.c.  of  arterial  Mood  often 
causes  death.  In  the  brain  the  chloroform  is  in  equilibrium  with  that  in 
the  blood.  If  a  fatal  result  ensues,  at  the  moment  of  the  heart's  arrest 
the  amount  in  the  venous  blood  is  more  than  in  the  brain,  but  afterward 
the  amount  in  the  brain  is  often  higher  than  in  the  venous  blood.  The 
amount  in  the  venous  blood  is  always  less  than  in  arterial  blood.  The 
length  of  the  period  of  anesthesia,  proportion  of  chloroform  in  the 
brain,  and  the  rapidity  of  blood  circulation  are  important  factors. 

1  Schaefer   and   Scharlieb :      Proc.   Physiol.    Soc,   1903,   17. 
2Etnbley  and  Martin:      J.  Physiol,  32,  147. 

3  Schaefer  and  Scharlieb :     Loc.  cit. 

4  Tissot:      Compt.    rend.,  142,  234. 


CHLOROFORM  301 

Meyer  and  Gottlieb  ^  have  directed  attention  to  the  narrow  margin 
between  a  therapeutic  dose  and  an  overdose  of  chloroform.  They  found 
that  in  deep  narcosis,  with  compensated  heart  action,  the  blood  content 
of  chloroform  is  0.035  per  cent,  whereas  in  the  blood  of  a  dog  anes- 
thetized to  the  point  of  cardiac  failure,  the  chloroform  content  was 
0.058  per  cent.  The  reason  for  this  narrow  margin,  they  hold,  is  that, 
in  spite  of  the  fact  that  respiration  ceases  first,  the  heart  is  the  .organ 
primarily  affected.  This  explains  why  artificial  respiration  often  fails 
unless  the  pressure  upon  the  chest  is  sufficiently  forcible  to  expel  the 
chloroform-laden  vapor  from  the  left  ventricle.  Otherwise  the  heart 
continues  to  be  poisoned.  The  left  ventricle,  which  is  principally  af- 
fected in  heart  failure,  was  found  by  Pohl,  according  to  Meyer  and 
Gottlieb,  to  contain  0.23  per  cent  of  chloroform,  whereas  the  right  heart 
contained  only  0.02  per  cent.  These  investigators  found,  in  some  of 
their  experiments,  that  chloroform  could  be  detected  in  the  blood  seven 
hours  after  cessation  of  the  anesthesia.  The  danger  comes,  not  from 
the  amount  of  chloroform  contained  in  the  blood,  but  from  its  hyper- 
saturation  with  the  vapor  at  some  one  time. 

Abel  -  found  that  in  the  stage  of  complete  anesthesia  the  brain  con- 
tains three  times  more  chloroform  than  an  equal  weight  of  blood;  blood 
containing  0.015  per  cent,  and  brain  substance  0.0118  per  cent.  The 
serum  of  the  blood  contains  very  little  chloroform  during  anesthesia, 
the  greater  part  that  is  taken  up  and  carried  by  the  blood  being  bound 
to  the  red  and  white  corpuscles. 

The  effect  of  chloroform  upon  the  heart  itself  has  been  the  subject 
of  much  investigation  and  wide  diversity  of  opinion.  By  some  ^  it  has 
been  maintained  that  primary  cardiac  paralysis  occurs  only  with  high 
percentages  of  vapor ;  by  others  *  it  has  been  claimed  that  permanent 
stoppage  of  the  heart  is  no  more  likely  to  occur  with  high  percentages 
than  with  low  ones.  These  views  have  been  challenged  by  those  ^  who 
hold  that  the  heart  is  never  primarily  affected,  its  action  being  maintained 
until  respiration  has  ceased.  Despite  these  diverse  findings,  it  is  now 
almost  unanimously  agreed  that  chloroform,  administered  to  the  degree 
of  surgical  narcosis,  acts  as  a  direct  heart  sedative  or  depressant,  and 
that  death  occurs  as  a  result  of  this  action. 

The  indirect  action  of  chloroform  upon  the  heart  has  also  given  rise 
to  diversity  of  opinion,  particularly  with  reference  to  the  question  of 
fatality.  Whether  this  action  is  the  indirect  result  of  the  irritation  by 
the  vapor  upon  the  sensory  nerve-endings  within  the  upper  air  and  pul- 

^  Meyer  and  Gottlieb:     ' ' Experimentelle  Pharmakologie. " 

^  Abel :   Bull.  Johns  HopMns  Eosp.,  Jan.,  1895. 

3  Snow:     "On  Chloroform  and  Other  Anaesthetics,"  1858. 

4Comm.  Royal  Med.  and  Chir.  Soe. ;    also,  Glasgow  Comm,    (1879-1880). 

5  First   Hyderabad   Commission,   1891. 


302  ANESTHESIA 

monary  passages,  giving  rise  to  stimulation  of  the  cardio-inhibitory 
center,  or  whether  it  is  a  direct  result  of  the  effects  upon  this  center  of 
the  anesthetic  circulating  in  the  blood,  has  not  been  determined. 

The  entire  subject  of  cardiac  inhibition  has  been  studied  experi- 
mentally by  Embley.^  He  found  that  cardio-inhibitory  effects  are  com- 
mon with  atmospheres  containing  more  than  two  per  cent  of  chloroform 
vapor.  The  degree  of  inhibition  increased  with  increasing  percentages 
of  the  vapor.  His  findings  with  reference  to  fatal  cardiac  inhibition 
are  not  in  keeping  with  those  of  the  Hyderabad  Commission.^  Embley 
held  that  slowing  or  complete  inhibition  of  the  heart's  action  did  not 
occur  in  animals  in  which  he  divided  the  vagi,  and  that  in  order  to 
bring  about  complete  and  permanent  cardiac  inhibition  more  injury  to 
the  heart  is  necessary  than  occurs  in  slight  chloroform  anesthesia.  The 
Hyderabad  Commission,  on  the  other  hand,  held  that  animals  may  be 
killed  by  vagus  excitation.  As  Hewitt  has  pointed  out,  the  possibility 
and  extent  of  the  application  of  these  and  similar  observations  to  human 
subjects  are  yet  to  be  determined. 

The  vasomotor  center  is  primarily  stimulated  by  chloroform,  and 
does  not  become  paralyzed  by  the  direct  action  of  the  agent  until  the 
stage  of  deepening  narcosis,  when  death  is  imminent. 

The  cause  of  death  from  the  administration  of  chloroform  has  been 
made  the  subject  of  so  much  experimental  and  clinical  investigation 
that  it  has  been  thought  advisable  to  consider  this  phase  of  the  action 
of  this  agent  upon  the  organism  under  a  special  heading. 

Effects  Upon  the  Nervous  System. — According  to  the  consensus  of 
opinion,  based  upon  clinical  observation,  chloroform  produces  a  pro- 
gressive paralysis  of  the  central  nervous  system,  the  order  in  which  this 
results  being  as  follows:  (1)  The  higher  cerebral  centers,  involving 
the  intellectual  faculties;  (2)  the  lower  cerebral  centers,  involving 
sensation  and  motion;  (3)  the  spinal  cord,  involving  reflex  action; 
(4)   the  medullary  centers,  involving  vital  function. 

For  purposes  of  convenience  the  above  order  will  be  followed  in  the 
ensuing  brief  discussion  of  the  effects  of  chloroform  upon  the  nervous 
system.  For  further  data  on  this  subject  see  the  Stages  of  Anesthesia, 
p.  306. 

Effects  Upon  the  Muscular  System. — The  effects  of  chloroform  upon 
the  muscles  of  the  heart  and  blood  vessels  have  been  discussed  under 
Effects  upon  the  Circulatory  System. 

Muscular  spasms  are  prone  to  characterize  the  ordinary  administra- 
tion of  chloroform,  this  tendency  being  the  greater  the  more  vigorous  is 
the  muscular  development  of  the  subject.     The  muscles  of  the  extrem- 

^  Embley :    ' '  The  Causation  of  Death  During  the  Administration  of  Choloro- 
form,"  Brit.  Med.  J.,  Apr.  5,  12,  19,  1902. 
^  Loc.  cit. 


CHLOROFORM  303 

ities,  abdomen,  chest,  larynx,  neck,  and  jaws  are  particularly  apt  to  be 
involved  in  tonic  spasms  during  the  earlier  stages  of  chloroform  anes- 
thesia. As  anesthesia  progresses  to  the  deeper  stages,  muscular  relax- 
ation follows  spasm,  as  a  rule.  Sometimes,  however,  clonic  spasms  of 
certain  muscles,  particularly  of  the  fingers  (piano-playing  movements), 
may  be  noted,  the  extremities  may  be  involved  in  slow,  coordinated 
movements,  or  jerky  adductor  movements  of  the  arms  may  occur,  pre- 
sumably as  the  result  of  clonic  contractions  of  the  muscles  of  the  chest. 
Spasmodic  tongue  retraction  may  occur,  giving  rise  to  stertor  and 
stridor. 

(For  the  important  significance  of  the  muscular  phenomena  of 
chloroform  anesthesia  see  Stages  of  Anesthesia,  p.  30G.) 

Effects  TJpon  the  Glandular  System  and  Other  Structures. — The 
mucous,  salivary,  and  sweat  glands  are  stimulated  to  hypersecretion  dur- 
ing light  chloroform  anesthesia. 

Nicloux  and  Fourquier  demonstrated  that  chloroform  has  a  special 
affinity  for  fat,  for  liver,  kidney,  spleen,  and  nerve  tissue,  and  for  striped 
muscle.  According  to  these  investigators  the  liver  of  the  fetus  is  even 
more  materially  affected  than  is  that  of  the  mother. 

Thompson  ^  conducted  a  large  number  of  animal  experiments,  which 
led  to  the  following  conclusions  with  reference  to  the  kidneys : 

(1)  The  volume  of  urine  secreted  by  the  kidneys  is  affected,  as  a 
rule,  during  chloroform  narcosis,  in  two  ways.  In  the  early  stages,  when 
the  anesthesia  is  light,  the  quantity  is  frequently  increased,  whereas, 
during  full  anesthesia,  the  secretion  is  always  diminished,  and  may  be 
suppressed. 

(2)  The  after-effect  is  invariably  a  great  increase,  which  may  reach 
to  four  times  the  normal  volume  for  the  same  period  of  time.  The 
maximum  outflow  may  occur  about  three  hours  after  removal  of  the 
anesthetic. 

(3)  The  total  excretion  of  nitrogen  is,  as  a  rule,  greatly  increased. 
The  averages  taken  from  experiments  with  diminished  urine  volume 
show  that  during  the  anesthetic  period  the  excretion  of  nitrogen  fell  to 
eighteen  per  cent  of  the  normal,  whereas  the  quantity  of  urine  in  the 
same  series  fell  only  to  thirty-five  per  cent  of  the  normal.  In  a  minor- 
ity of  the  experiments  with  increased  urine  volume,  the  total  nitrogen 
per  period  was  also  increased,  but  to  a  much  less  extent  than  the  volume 
of  urine  in  the  same  experiments. 

(4)  The  urine  secreted  during  chloroform  anesthesia  is  almost  in- 
variably more  dilute  (contains  a  lower  percentage  of  nitrogen)  than  the 
normal  urine.  This  holds  good  even  when  the  volume  of  urine  is  dimin- 
ished.   Hence  it  is  inferred  that  chloroform  affects  not  only  the  blood 

^Thompson:  "Anaesthetics  and  Eenal  Activities,"  Brit.  Med.  J.,  Mar.  17, 
1906. 


304  ANESTHESIA 

flow  through  the  glomerules,  but  also  the  secretion  of  nitrogenous  solids 
in  the  tubules,  the  latter  being  even  more  marked  than  the  former. 

(5)  There  is  a  general  but  not  accurate  correspondence  between 
urine  outflow,  kidney  volume,  and  blood  pressure.  The  relationship  be- 
tween the  first  and  second  is  closer  than  that  between  the  first  and 
third. 

(6)  In  prolonged  narcosis,  with  marked  diminution  of  urine  volume, 
there  is  a  considerable  exudation  of  leucocytes  in  the  renal  tubules, 
which  subsequently  escape  with  the  urine.  The  condition  is  probably 
produced  by  more  or  less  vascular  stasis  in  the  glomerular  vessels. 

(7)  The  excretion  of  chlorids  is  much  increased  both  during  and 
after  chloroform  narcosis.  In  the  fourth  period,  after  the  removal  of 
the  anesthetic,  the  amount  in  the  urine  of  the  dog  may  be  ten  times  the 
normal  quantity. 

(8)  Albumin  appears  in  a  small  proportion  of  experiments  after 
chloroform  inhalation. 

(9)  Eeducing  substances  other  than  glucose  are  almost  invariably 
increased.  The  nature  of  the  reducing  substance  has  not  been  definitely 
determined. 

Chloroform,  according  to  Apperly's  ^  observations,  affects  the  cells  of 
the  liver,  interfering  with  the  metabolism  of  fats.  The  poisonous  fatty 
acids,  which  cause  an  acid  intoxication,  are  thus  thrown  out  into  the 
blood.  The  cells  lining  the  tubules  of  the  kidneys  are  so  damaged  that 
their  excretory  function  is  interfered  with.  As  acute  infections,  espe- 
cially of  the  peritoneum,  cause  changes  in  the  same  organs,  chloroform 
should  not  be  given  in  these  cases. 

According  to  Delbet  ^  and  his  co-workers,  chloroform  has  a  special 
affinity  for  the  adrenals  and  checks  their  functioning.  These  effects  are 
responsible,  they  hold,  for  operative  shock  and  for  sudden  quiet  death 
in  coma  after  an  operation.  Delbet  injects  0.0004  or  0.0006  gm.  epine- 
phrin  subcutaneously  at  the  beginning  of  the  operation,  thus  rendering 
anesthesia  more  regular,  diminishing  operative  shock,  and  lessening  the 
frequency  of  sudden  post-operative  fatalities.  If  prostration  continues, 
another  dose  of  epinephrin  is  given  the  next  day. 

Levy's  ^  investigations  seem  to  prove  that  epinephrin  may  be  safely 
injected  just  before  induction,  or  during  deep  anesthesia,  but  that  a 
certain  definite  risk  is  taken  when  injection  is  made  during  light  chloro- 
form anesthesia. 

For  further  discussion  of  the  effects  of  chloroform  upon  the  glandu- 

*  Apperly,  E.  E. :  "  Effect  of  Chloroform  and  Ether  on  Liver  and  Kidneys 
in  Health  and  Its  Significance  in  Certain  Infective  Conditions,"  Brit.  Med.  J., 
Sept.  14,  1912,  S,  2698. 

^Delbet:     Bevue  de  CMrurgie,  1912,  No.  4,  32. 

"Levy:    Brit.  Med.  J.,  Sept.  14,  1912. 


CHLOROFORM  305 

lar  system,  see  sections  on  Elimination,  p.  309,  and  After-Effects,  p. 

310. 

Causes  of  Death  from  the  Administration  of  Chloroform. — In  sum- 
ming up  the  action  of  chloroform  upon  the  organism,  Hewitt  says  ^ : 
"So  far  as  we  have  gone,  then,  it  would  seem  that  we  have  in  chloroform 
a  drug  which  is  a  powerful  protoplasmic  poison;  which,  when  given  in 
toxic  quantities,  leads  to  death  of  the  organism,  not  because  it  paralyzes 
respiration — for,  were  it  merely  a  respiratory  depressant,  artificial  respi- 
ration would  be  invariably  successful  in  averting  death — but  because,  as 
recent  researches  have  shown,  it  markedly  depresses  the  circulation.  It 
is  this  circulatory  depression  which  renders  it  difficult  to  resuscitate 
patients.  The  fact  that  an  overdose  of  chloroform  generally  paralyzes 
respiration  before  the  heart's  action  finally  ceases  must  not  be  allowed  to 
overshadow  the  more  important  fact  that,  prior  to  and  during  the  res- 
piratory failure,  the  heart  has,  in  many  cases,  ceased  to  circulate  blood 
through  the  organism.  Whether  in  true  chloroform  toxemia  the  fatal 
circulatory  failure  is  principally  (a)  a  failure  of  cardiovascular  origin 
due  to  chloroform  directly  affecting  the  musculature  of  the  vascular 
system  as  a  whole;  whether  it  is  principally  (b)  a  failure  of  cardiac 
origin,  the  chloroform  directly  affecting  the  cardiac  muscle  relatively 
more  than  the  walls  of  the  arteries  and  arterioles;  whether  it  is  prin- 
cipally (c)  a  failure  due  to  the  action  upon  the  nervous  mechanism  which 
controls  cardiac  action;  or  whether  it  is  principally  (d)  due  to  a  paraly- 
sis of  the  vasomotor  mechanism — we  cannot  at  present  positively  say." 

According  to  Gill :  ^  "In  narcosis  which  runs  its  course  uncompli- 
cated by  vasomotor,  stomachic,  or  (primary)  cardiac  disturbance  the 
ultimate  cause  of  death  is  oxygen-starvation.  The  respiratory  muscles 
tend  to  become  exhausted,  and  their  failure  to  act  forms  a  proximate 
cause:  the  action  of  the  heart  also  tends  to  fail,  and  cardiac  syncope, 
indirectly  induced  by  the  negative  action  of  the  agent  when  in  the  form 
of  vapor,  becomes  the  intermediary  means  of  the  causation  of  death. 
The  question  which  fails  first,  the  heart  or  the  action  of  the  respiratory 
machine,  will  be  decided  by  the  initial  condition  of  the  former.  If  the 
heart  be  abnormal,  and,  in  consequence,  less  able  than  normally  to  with- 
stand increased  pressure  in  its  right  ventricle,  it  will  fail  before  the 
respiration.  But  if  the  heart  be  normal,  the  action  of  the  respiratory 
machine  will  cease  before  the  pulse  disappears,  because  the  power  of 
resistance  possessed  by  the  respiratory  muscles  is  known  to  be  less  than 
that  of  the  heart." 

Luke  and  Ross  ^  attribute  chloroform  deaths  to  cardiac  syncope  aris- 
ing from  the  following : 

"^Loc.  cit.,  1912,  126. 

2  Gill,  Eichard:     "The  CHCl^  Problem,"  3,  Physiological  Action,  284. 

3  Luke   and   Eoss:      "Anaesthetics,"    3rd   ed.,    192. 


306  ANESTHESIA 

(1)  Beflex  stimulation  of  the  vagus,  causing  inhibition  of  the  cardiac 
pulsations  (during  light  anesthesia). 

(2)  The  depressant  action  of  the  chloroform  on  the  medullary  cen- 
ter of  the  heart,  the  vasomotor  center,  the  intrinsic  ganglia,  and  the 
myocardium  itself  (in  deep  anesthesia  from  overdose). 

(3)  Cessation  of  respiration  by:  (a)  Direct  obstruction  from  laryn- 
geal stertor,  or  from  the  falling  back  of  the  tongue;  (b)  Direct  retarda- 
tion and  arrest  of  the  pulmonary  circulation,  first  in  the  capillaries  and 
later  in  the  larger  vessels,  due  to  the  direct  local  action  of  chloroform; 
(c)  Interference  with  the  respiratory  center  in  the  medulla,  and  the 
subordinate  centers  in  the  spinal  cord. 

Stages  of  Anesthesia. — Under  the  caption.  Factors  Which  May  Be 
Said  to  Modify  the  Physiology  of  Anesthesia  as  Ordinarily  Induced 
(p.  63),  attention  is  directed  to  the  fact  that,  in  the  experience  of  one 
of  us  (J.  T.  G.),  the  phenomena  observed  during  the  administration 
of  inhalation  anesthetics  are  modified,  to  a  more  or  less  pronounced 
degree,  by  certain  procedures  now  employed  by  a  number  of  anesthetists. 
This  modification  is  particularly  to  be  noted  in  the  sequence  of  events 
commonly  described  as  stages  of  anesthesia.  It  is  to  be  borne  in  mind, 
however,  that  in  the  present  discussion  of  the  physiology  of  chloroform, 
as  manifested  in  these  stages,  reference  is  made  to  the  administration  as 
ordinarily  given,  and  not  with  the  utilization  of  the  various  factors 
mentioned. 

Four  stages  of  chloroform  anesthesia  are  usually  described.  It 
should  be  noted,  however,  that  the  division  of  chloroform  narcosis  into 
these  four  stages  is  more  or  less  arbitrary.  Administered  by  modern 
methods,  with  proper  care,  the  induction  period  is  so  gradually  merged 
into  that  of  surgical  anesthesia  that  only  the  keenest  observer  is  able  to 
detect  the  successive  steps.  On  the  other  hand,  when  improperly  admin- 
istered, the  induction  period  passes  so  quickly  into  the  fourth  stage,  or 
stage  of  overdose,  that  the  anesthetist  is  unable  to  detect  the  danger 
signals  until  it  is  too  late.  For  this  reason,  it  is  often  stated  that  death 
from  chloroform  most  frequently  occurs  during  the  initial  stage. 

The  First  Stage^  or  Stage  of  Light  Anesthesia. — The  first  few 
drops  of  chloroform  may  have  no  appreciable  effect  upon  the  subject, 
except  to  stimulate  respiration  and  circulation.  If  a  light  vapor  (two 
per  cent  of  chloroform  in  the  air  inhaled)  is  administered,  practically 
no  subjective  phenomena  are  noted  during  this  stage,  which  is  of  longer 
duration  under  these  circumstances  than  when  a  more  concentrated 
vapor  is  employed.  With  the  heavier  vapor,  breath-holding,  coughing, 
resistance  to  the  anesthetic,  and  other  disturbances,  such  as  retching, 
vomiting,  or  cyanosis,  may  occur.  The  pupil  may  enlarge,  all  the  senses 
may  become  slightly  more  active,  and  incoherency  of  ideas  and  speech 
may  become  apparent. 


CHLOROFORM  307 

Analgesia  appears  at  this  stage,  but  operation  should  not  be  under- 
taken at  this  time,  as  the  reflexes  are  often  exaggerated,  and  death  may 
result  from  reflex  cardiac  inhibition.  An  increase  in  the  heart's  action 
and  a  rise  of  blood  pressure  are  invariably  present. 

The  cerebral  centers  are  affected  in  this  stage.  Different  subjective 
sensations,  such  as  ringing  and  roaring  sounds,  may  be  present,  usually 
varying  with  the  vapor  concentration,  but  sometimes  occurring  despite 
the  careful  administration  of  the  vapor. 

The  breathing  is  usually  deep  and  regular,  and  the  pulse  quick  and 
full. 

The  order  of  disappearance  of  reflexes  during  this  stage  is:  (1) 
superficial  skin;    (2)  vomiting;    (3)  swallowing;    and  (4)  coughing. 

The  Second  Stage,  or  Stage  of  Excitement. — This  stage  should 
never  occur  when  chloroform  is  properly  administered.  (See  Adminis- 
tration, p.  311.)  Carelessly  employed,  however,  chloroform  anesthesia 
may  be  marked  by  a  definite  stage  of  excitement,  during  which  the 
respiration  becomes  irregular,  the  pulse  becomes  more  rapid,  there  may 
be  struggling,  shouting,  disconnected  talking,  crying,  and  laughing.  The 
face  is  flushed,  and  the  pupils  continue  dilated.  Muscular  spasms,  par- 
ticularly spasm  of  the  muscles  of  the  jaw  and  neck,  chest,  and  abdomen 
may  occur,  indicating  the  need  of  air. 

When  the  chloroform  vapor  is  too  dilute  the  patient,  if  a  child,  may 
pass  into  a  "chloroform  sleep";  if  an  adult,  vomiting  may  be  induced. 
"False  anesthesia"  is  known  to  be  present  when  a  patient  consciously  or 
unconsciously  begins  breathing  automatically,  when  the  anesthetist 
knows  that  not  enough  chloroform  has  been  given  to  induce  full  surgical 
anesthesia.  It  is  best  to  ignore  the  pupil  and  corneal  reflexes  at  this 
time.  If  respiration  is  slow,  or  if  it  interferes  with  the  quiet  induction 
of  full  surgical  anesthesia,  a  few  drops  of  ether  upon  the  mask  will 
usually  remedy  this  trouble.  The  eyes  are  poor  guides  at  this  time.  The 
pupils  are  usually  widely  dilated,  the  eyeballs  may  move  from  side  to 
side,  or  may  be  stationary.  As  the  anesthetic  is  increased  in  strength, 
the  movements  of  the  eyes  become  less  marked,  the  muscles  relax,  and 
the  subject  passes  into  the  third  stage. 

Stertor  may  occur,  but  is  not  necessarily  indicative  of  anesthesia. 
Vomiting  will  take  place  if  the  stage  of  excitement  is  unnecessarily  pro- 
longed, its  imminence  being  indicated  by  feeble,  small  pulse. 

The  cerebellar  centers  are  now  progressively  affected.  Sensibility  to 
pain  is  greatly  diminished.  The  patient  may  answer  questions,  of  which 
there  is  no  recollection  afterwards.  There  may  be  unintelligent  mutter- 
ings. 

With  alcoholic  and  athletic  patients  it  is  difficult  to  induce  anesthesia 
without  a  conspicuous  stage  of  excitement. 

By  the  maintenance  of  an  open  airway,  by  the  manipulation  of  the 


308  ANESTHESIA 

lower  jaw  in  such  a  way  that  the  presence  of  an  open  airway  is  always 
apparent,  and  by  the  insistence  upon  absolute  silence  in  the  room,  the 
anesthetist  may  successfully  carry  a  patient  from  the  induction  period 
into  full  surgical  narcosis  without  any  signs  of  the  stage  of  excitement. 

The  Third  Stage,  or  Stage  of  Surgical  Anesthesia. — In  this 
stage  the  muscles  are  relaxed,  the  pupils  contract  to  normal  size,  the 
respiration  (this  is  the  principal  guide)  becomes  regular  and  automatic. 
Phonation  and  the  conjunctival  and  corneal  reflexes  disappear.  The 
pulse  rate  is  lessened,  and  the  face  becomes  pale.  When  the  pulse  rate 
falls  below  fifty,  and  extreme  pallor  is  present,  shock  is  imminent.  The 
pulse  should  be  normal,  or  a  little  below  normal. 

When  the  stage  of  surgical  anesthesia  is  established,  which  usually 
requires  from  four  to  eight  minutes,  it  must  be  maintained.  A  lighten- 
ing of  the  anesthesia  may  affect  the  vomiting  center. 

The  eyes  are  usually  fixed  during  this  stage,  with  the  pupils  con- 
tracted but  responding  to  light.  Hewitt  found,  by  taking  measurements 
with  the  pupillometer  (see  illustration,  p.  195),  that  in  most  cases  the 
pupil,  in  this  stage,  measures  from  two  to  three  millimeters  in  diameter, 
usually  about  two  and  a  half  millimeters.  Occasionally  it  remains  widely 
dilated.  "A  very  small  pupil  (1  to  I14  mm.),"  Hewitt  says,  "in  most 
cases  indicates  a  light  anesthesia;  while  a  somewhat  dilated  pupil  (31/2 
to  4I/2  mm.)  usually  means  either  that  the  anesthesia  is  very  profound, 
or  more  probably  that  the  dilatation  is  of  reflex  origin  and  is  associated 
with  a  light  anesthesia." 

The  muscular  phenomena  of  the  stage  of  surgical  anesthesia  are 
important  danger  signals.  As  previously  stated,  complete  muscular 
relaxation  should  accompany  this  stage.  Under  the  caption.  Effects 
upon  the  Muscular  System,  attention  is  directed  to  the  fact  that  surgical 
anesthesia  may  be  accompanied  by  certain  clonic  muscular  movements, 
as  well  as  by  slow,  coordinated  movements  of  certain  muscles,  and  by 
jerky  adductor  movements  of  the  arms  following  spasm  of  the  pectoral 
muscles.  The  significance  of  these  phenomena  is  that  they  may  be  taken 
by  the  anesthetist  or  by  the  surgeon  to  indicate  a  lightening  of  the  anes- 
thesia; in  other  words,  a  return  to  the  second  stage.  If,  under  this 
misapprehension,  the  anesthetic  is  pushed  with  a  view  to  obtaining  more 
perfect  relaxation  and  quietude,  the  subject  may  be  at  once  plunged  into 
a  condition  of  apnea,  which  may  eventuate  in  respiratory  paralysis  and 
death. 

The  third  stage  is  always  marked  by  a  lowering  of  body  temperature. 

The  order  of  disappearance  of  reflexes  in  the  third  stage  is  as  follows : 
(1)  phonation;  (2)  conjunctival;  (3)  corneal;  (4)  pupil  to  light; 
( 5 )  bladder  and  rectal.    The  last  two  disappear  with  deepening  narcosis. 

The  Fourth  Stage,  Stage  of  Deepening  IsTarcosis,  or  Stage  of 
Overdose. — It  has  been  previously  stated  that  the  subject  may  pass  so 


CHLOROFORM  309 

quickly  from  the  first  stage,  or  the  induction  period,  into  the  stage  of 
overdose,  that  the  intervening  phenomena,  the  danger  signals,  cannot  be 
noted,  and.  that  death  supervenes,  therefore,  during  the  first  few  minutes 
of  the  administration.  The  present  discussion  of  the  stage  of  overdose, 
however,  refers  not  to  this  state  of  affairs,  but  to  the  more  gradual 
sequence  of  events,  with  culmination,  through  misapprehension  of  condi- 
tions, or  other  exigencies  of  administration,  in  what  has  come  to  be 
known  as  the  fourth  stage. 

The  ushering  in  of  this  stage  is  indicated  by  extreme  pallor,  abolition 
of  all  reflexes,  and  very  great  relaxation  of  the  muscles.  The  breathing 
becomes  more  and  more  shallow;  the  pulse  becomes  weaker,  irregular, 
and  thready.  Blood  pressure  continues  to  fall.  Vasomotor  paralysis, 
sudden  or  gradual  respiratory  failure,  and  complete  cardiac  inhibition 
are  the  final  phenomena  of  the  stage  of  overdose,  which  thus  culminates 
in  death. 

Elimination. — From  studies  upon  the  influence  of  chloroform  on 
intravital  staining  with  methylene-blue  it  has  been  found  ^  that,  although 
the  results  in  rabbits  were  not  uniform,  evidence  was  obtained  of  dimin- 
ished reduction  on  the  part  of  chloroformed  brains.  The  increased  cir- 
culation of  the  dye  in  the  blood  is  due  to  the  impaired  excretory  activ- 
ities of  the  kidneys  and  liver.  This  explains  a  more  abundant  passage 
of  the  dye  into  the  digestive  tract,  and  the  tint  of  the  blood  in  part 
accounts  for  the  appearance  of  the  brain.  The  muscles,  however,  are  less 
deeply  stained  than  in  control  animals. 

The  amount  of  chloroform  in  the  urine  of  dogs,  subjected  for  pro- 
longed periods  to  the  anesthetic,  has  been  found  ^  to  be  extremely  small, 
namely,  from  6  to  8  mg.  per  100  c.c.  of  urine.  The  urine  after  anes- 
thesia, it  has  been  noted,  has  a  high  specific  gravity,  a  strongly  acid 
reaction,  and,  in  70  per  cent  of  the  cases  examined  by  Baldwin  ^  (40  in 
number),  there  was  a  marked  acetone  reaction,  due  to  a  disturbance  of 
metabolism,  probably  in  the  liver  cells.  Tests  made  by  Vitali  *  with 
urine  of  four  patients,  during  and  after  the  administration  of  chloro- 
form, revealed  the  fact  that  chloroform  did  not  pass  into  the  urine,  and 
that  the  presence  in  the  urine  of  other  organic  chlorin  compounds  could 
not  be  detected.  This  observation  is  not  in  harmony  with  the  findings 
of  others,^  who  state  that  the  urine  may  show  traces  of  chloroform,  the 
drug  existing  in  an  unchanged  state  for  as  long  as  twelve  days  after 
administration. 

^Herter  and  Eichards:    Am.  J.  Physiol.,  12,  297. 
^  Nicloux :    J.  pharm.   chim.,   1906,  24,   64. 

*  Baldwin:     J.  Biol.  Chem.,  1,  239. 

*  Vitali:      L'Oroso,  22. 

5  Thien  and  Fischer:  Deutsch.  med.  Zig.,  Dec.  2,  1889.  See  also  Demeraux 
and  Minet:      L'Echo   med.,  June,   1904. 


310  ANESTHESIA 

Chloroform  is  largely  excreted  through  the  expired  air,  according  to 
Meyer  and  Gottlieb.^  A  small  part  is  broken  down  in  the  organism, 
increasing  the  chlorid  content  of  the  urine. 


INDICATIONS    AND     CONTRAINDICATIONS 

The  indications  and  contraindications  for  chloroform  may  be  cate- 
gorically stated.  For  further  discussion  of  the  subject  see  Chapter  VIII, 
Selection  of  Anesthetic. 

Indications. —  (1)  Obstetrical  cases,  in  which  the  heart  is  usually 
hypertrophied  and  only  primary  anesthesia  is  required;  (2)  young  chil- 
dren, particularly  as  an  introduction  to  ether;  (3)  old  people,  as  a  pre- 
liminary to  ether;  (4)  persons  afflicted  with  epilepsy,  convulsive  seizures 
of  any  hind,  tetanus;  (5)  affections  of  the  respiratory  system — pul- 
monary tuberculosis,  asthma,  emphysema ;  (6)  aneurysm;  (7)  pleurisy; 
(8)  operations  involving  the  upper  respiratory  tract— excision  of  tongue, 
inferior  or  superior  maxillae,  enlarged  glands,  or  tumors  that  encroach 
upon  the  airway;  (9)  operations  in  which  the  Trendelenburg  position 
is  indicated;  (10)  obese  and  flabby  patients,  particularly  as  an  intro- 
ductory anesthetic;  (11)  insane  patients;  (12)  operations  upon  the 
brain;  (13)  operations  in  which  the  actual  cautery  is  to  be  used  close 
to  the  face. 

Contraindications. —  (1)  WeaJc,  anemic  children,  with  enlarged 
glands  in  different  parts  of  the  body;  (2)  status  lymphaticus  (see  Chap- 
ter VIII,  Selection  of  Anesthetic) ;  (3)  very  prolonged  operations ; 
(4)  minor  surgery,  when  a  safer  anesthetic  is  available;  (5)  all  opera- 
tions where,  for  any  reason,  the  patient  is  in  the  sitting  posture,  or  when 
the  body  must  be  raised  to  this  position  during  the  operation;  (6)  ath- 
letes and  alcoholics  who  have  had  no  preliminary  medication.  (7) 
patients  whose  general  condition  is  poor,  as  indicated  by  a  weak,  anemic 
appearance;  (8)  general  septic  conditions,  especially  when  due  to  long- 
standing tuberculous  glands ;  (9)  diabetic  patients;  (10)  very  thin  per- 
sons, not  otherwise  diseased;^  (11)  cyanosis  already  present;  (12)  low 
blood  pressure  from  any  cause;    (13)  the  presence  of  an  open  flame. 

After-Eflfects. — The  after-effects  of  chloroform  narcosis  may  be  con- 
sidered under  two  heads,  viz.:     (1)  immediate,  and  (2)  remote. 

1  Meyer  and  Gottlieb :     Loc.  cit. 

2  ' '  How  strong  a  factor  the  fat  plays  is  shown  by  the  experiment  on  hungry 
animals  where  the  brain  takes  up  much  more  anesthetic  than  on  well-fed  animals 
in  whom  the  fatty  tissues  absorb  part  of  such  narcotic.  From  these  experiments 
we  can  readily  imagine  the  absorption  of  narcotics  by  the  lipoids  of  the  nervous 
system  during  the  narcosis  and  the  return  of  function  with  their  excretion  back 
to  the  blood  and  the  still  further  excretion  of  the  anesthetic  through  the  lungs. ' ' 
Meyer  and  Gottlieb:     " Experimentelle  Pharmakologie. " 


CHLOROFORM  311 

Immediate  After-effects. — If  chloroform  is  scientifically  admin- 
istered to  a  patient  carefully  prepared,  and  under  proper  climatic  condi- 
tions, the  subject  passes  into  a  profound  sleep,  awakening  as  from  nat- 
ural slumber.  Under  other  circumstances,  however,  the  awakening  may 
be  accompanied  by  nausea,  retching,  and  vomiting,  with  pallor  and 
almost  imperceptible  pulse.  Hiccough  sometimes  proves  an  annoying 
after-effect.  As  a  rule,  with  chloroform,  bronchial  and  pulmonary 
sequelae  are  absent.  In  neurotic  and  hysterical  individuals  mental  dis- 
turbances, sometimes  amounting  to  maniacal  seizures,  may  follow.  De- 
lirium of  three  days'  duration  has  been  reported.  Aphasia  has  also  been 
reported  as  following  chloroform. 

Eemote  After-Effects. — Fatty  infiltration  of  all  the  organs,  ac- 
cording to  some  observers,  follows  the  prolonged  or  repeated  administra- 
tion of  chloroform.  Eatty  degeneration  of  the  liver,  the  heart,  and  the 
kidneys  is  particularly  apt  to  occur  under  these  circumstances,  this  being 
the  outcome  of  a  direct  poisoning  of  these  organs  by  the  drug.  Even 
when  given  in  repeated,  very  small  amounts,  chloroform  will  lead  to 
atrophic  cirrhosis  of  the  liver. 

Albuminuria,  acetonuria,  urobilinuria,  acetonemia,  acidosis,  which 
have  been  noted  by  various  observers  as  following  chloroform  anesthesia, 
are  discussed  under  the  special  head,  Post-Anesthetic  Toxemia,  in  Chap- 
ter IX,  Treatment  Before,  During,  and  After  Anesthesia. 

Comparison  With  Other  Agents. — It  is  important  for  the  anesthetist 
to  bear  in  mind  the  relative  anesthetic  value  of  the  agent.  The  strength 
of  chloroform  as  an  anesthetic,  as  compared  to  ether,  is  calculated  by 
Hewitt  as  6  to  1,  by  Cushny  as  8  to  1.  Its  anesthetic  power  is  greater 
than  that  of  ethyl  chlorid. 


ADMINISTRATION    OF    CHLOROFORM 

Drop  Method. — When  chloroform  was  first  introduced  by  Simpson, 
the  method  employed  consisted  in  putting  an  unmeasured  quantity  of 
chloroform  on  a  handkerchief,  placing  the  handkerchief  thus  treated 
over  the  nose  and  mouth  of  the  patient,  and  continuing  the  administra- 
tion in  a  somewhat  similar  manner.  Not  many  years  elapsed  before  the 
necessity  for  a  different  method  suggested  itself.  Simpson  then  advised 
that  a  single  layer,  of  a  towel  or  a  handkerchief,  should  be  placed  over 
the  patient's  nose  and  mouth,  and  that  the  anesthetic  be  added,  drop  by 
drop.  This  proved  to  be  so  much  safer  than  the  first  way  of  administer- 
ing chloroform  that  the  method  has  been  advocated  by  every  ^vriter 
since  that  time.  Inasmuch  as  the  drop  method  will  unquestionably  con- 
tinue to  be  employed,  and  inasmuch  as  many  will  continue  to  use  chloro- 


312 


ANESTHESIA 


form  alone,  it  is  important  that  the  safest  method  of  administration  in 
this  way  be  considered. 

The  Patient.^ — It  is  more  important  with  chloroform  than  with 
any  other  anesthetic  that  the  head  be  on  a  line  with  the  body.  If  a  pillow 
is  placed  under  the  head  it  should  be  pushed  under  the  shoulders,  in 
order  to  prevent  asphyxial  symptoms  during  the  second  stage.  This 
pillow  should  be  removed  as  the  third  stage  is  reached.  If  in  the  dorsal 
position,  the  head  should  be  turned  slightly  to  one  side,  the  anesthetist 
holding  the  symphysis  of  the  jaw  with  the  index  finger,  the  little  finger 
resting  upon  the  carotid  artery;  the  left  hand  shoiild  hold  the  chloro- 
form dropper.     The  clothing  should  be  perfectly  loose,  shoes  and  stock- 


FiG.  123. — The  Pilling  Chloroform  Dropper. 


ings  being  removed ;  a  tight  waist  or  neckband  will  materially  interfere 
with  what  might  otherwise  be  a  featureless  narcosis.  If  bandages  are 
on  the  neck  or  around  the  waist,  these  should  be  cut  but  not  necessarily 
removed  before  the  operation  begins. 

The  Droppek. — It  is  even  more  important  that  chloroform  should 
be  dropped  from  the  original  container  than  ether  or  other  inhalation 
anesthetics ;  therefore,  containers  arranged  for  dropping  should  be  used. 
If  not  so  arranged  ^  the  dropper  recommended  under  ether  will  serve 
satisfactorily. 

Induction. — As  the  vast  majority  of  chloroform  fatalities  reported 
have  occurred  in  the  first  few  minutes  of  administration,  it  is  most 
important  that  the  psychical  element  be  controlled  as  much  as  possible, 
both  by  preliminary  medication  and  by  the  conversation  of  the  nurses, 
physicians,  or  friends  who  may  be  near.  In  addition  the  anesthetic  will 
go  much  more  smoothly  if  some  Farina  colo,gne  is  dropped  upon  the 

^For  general  preparation  of  patient  see  Chapter  IX,  Medication,  Prelim- 
inary,  During,   and  Post-anesthesia. 

"■  Tracings  on  a  smoked  drum  indicate  that  the  blood  pressure  is  maintained  at 
a  much  higher  level  when  the  anesthetic  is  induced  slowly,  as  here  outlined. 


CHLOROFORM 


313 


mask.  This  should  be  supplemented  in  one-half  mi  mite  l)y  one  or  two 
drops  of  aromatic  spirits  of  ammonia,  or,  preferably,  of  an  aleobolic 
solution  of  the  oil  of  bitter  orange  peel.^  The  first  drop  of  chloroform 
can  now  be  administered,  and  in  30  seconds  the  second  drop,  that  is, 
two  drops  the  first  minute.  This  can  be  increased  to  six  drops  the 
second  minute.  The  third  minute,  two  drops  may  be  given  every  ten 
seconds;  the  fourth  minute,  three  to  four  drops  every  ten  seconds;  the 
fifth  minute,  five  to  ten  drops  every  ten  seconds.  If  the  patient  is  not 
in  full  surgical  anesthesia  at  this  time,  the  administration  may  be  con- 
tinued as  follows:  eight  or  ten  drops  every  ten 
seconds  for  one  or  two  minutes  longer.  No  time 
is  wasted  by  beginning  the  administration  of 
chloroform  very  slowly.  The  mucous  membranes 
are,  in  a  measure,  blunted,  and,  if  conducted 
methodically  in  this  way,  the  surgical  stage  will 
be  ushered  in  by  the  automatic  respirations  of  the 
patient,  the  first  and  second  stages  not  being  ob- 
served ordinarily. 

Maintaining  Surgical  Anesthesia. — When 
the  surgical  stage  is  reached  the  amount  necessary 
to  continue  the  anesthesia  will  be  found  to  be  one- 
half  of  the  amount  necessary  to  induce  anesthesia ; 
that  is  to  say,  if  seven  drops  every  ten  seconds 
induce  surgical  anesthesia  in  six  minutes,  three  or 
four  drops  every  ten  seconds  will  easily  maintain 

an  even  plane  of  anesthesia.  When  the  third  stage  is  reached,  however,  it 
is  well  for  the  anesthetist  to  continue  dropping  the  maximum  amount 
for  one  or  two  minutes  and  then  to  go  back  to  three  drops  every  ten 
seconds  for  the  next  minute  or  so,  and  then  to  decrease  this  amount  to 
two,  or  increase  to  three  or  four  drops  every  ten  seconds  continuously, 
after  that  depending  upon  the  patient's  reflexes. 

In  surgical  anesthesia  the  muscles  are  relaxed,  the  pupil  contracts 
to  normal,  the  respirations  (and  this  is  the  principal  guide)  become 
regular  and  automatic.  The  reflexes  disappear;  the  pulse  slows  down, 
and,  with  chloroform  alone,  the  face  is  usually  pale.  "A  pulse  below  50 
and  extreme  pallor  are  danger  signals  for  the  circulation."  ^ 

The  respiration  is  slow,  regular,  and  deep;  all  motor  senses  except 
those  of  respiration  and  circulation  are  completely  depressed. 

It  usually  requires  from  four  to  eight  minutes  to  reach  full  surgical 
anesthesia. 

When  surgical  anesthesia  is  finally  obtained  the  patient  must  be  kept 
in  this  stage.     A  lightening  of  the  anesthesia  may  touch  the  vomiting 

^  See  Chapter  II,  General  Physiology. 
-  Meyer  and  Gottlieb :    Loc.   cit. 


Fig.  124.— a  Chloro- 
form Dropper  which 
Should  Never  be 
Used. 


314  ANESTHESIA 

center  and  trouble  will  immediately  follow.  The  pulse  should  be  normal, 
or  a  little  below  normal ;  if  oxygen  or  ether  is  given,  and  the  anesthetic 
warmed,  it  will  be  normal,  or  just  a  little  above.  The  eyes  are  usually 
fixed  during  this  stage,  with  pupils  contracted  but  responding  to  light 
unless  morphin ,  has  been  previously  given.  When  morphin  has  been 
given  the  pupils  are  contracted  throughout.  In  abdominal  operations  it 
is  usually  necessary  to  abolish  the  lid  reflex ;  where  muscular  relaxation 
is  not  required  this  reflex  may  be  allowed  to  remain.  In  either  case  the 
reflex  should  not  be  consulted  oftener  than  once  every  two  or  three 
minutes.  It  must  be  remembered  that  patients  differ  in  all  of  these 
things.  It  is  best,  therefore,  to  be  guided  by  all  available  signs,  viz.: 
respiration,  circulation,  lid  and  color  reflex,  and  amount  of  anesthetic 
given. 

In  the  third  stage  the  spinal  nerves  are  affected.  With  the  drop 
method  the  face  is  usually  pale,  but  when  administered  with  oxygen  the 
cheeks  are  usually  flushed  and  the  patient  presents  a  very  natural  appear- 
ance. There  is  usually  a  reduction  of  body  temperature  when  given  by 
the  drop  method,  but  with  warmed  oxygen  the  normal  temperature  is 
usually  maintained,  or  slightly  raised. 

Warmed  Chloroform. — The  chloroform  container  should  be  dipped 
into  a  pan  of  hot  water,  from  time  to  time,  to  facilitate  the  vaporization 
of  the  liquid.  It  is  much  safer  to  use  the  drug  in  this  manner.  Occa- 
sionally the  mask  should  be  entirely  removed  from  the  face  for  one  or 
two  respirations.  The  anesthetist  must  anticipate  stages  by  careful 
observation  of  his  patient.  Siirgical  anesthesia  may  be  maintained  as 
follows:  If  three  drops  are  given  for  ten  seconds  the  patient  will  grad- 
ually come  out  of  the  anesthetic  stage.  As  the  pulse  goes  up  and  becomes 
full  and  bounding,  the  color  improves  and  the  reflexes  become  slightly 
active ;  this  dosage  can  be  increased  to  five  or  seven  drops  every  ten  sec- 
onds for  a  minute  or  so.  As  the  reflexes  become  blunted  again  the  anes- 
thetist should  go  back  to  three  drops  every  ten  seconds  and  continue  as 
before.  This  method  of  administration  by  a  watch  relieves  the  anes- 
thetist of  a  tremendous  nerve  strain  and  enables  him  to  produce  a  con- 
tinuous and  safe  narcosis. 

In  order  to  determine  the  comparative  value  of  chloroform  as  regards 
life  when  heated  to  100°  F.,  and  at  normal  temperature,  a  number  of 
experiments  were  made,  using  compressed  air,  and  passing  this  air 
through  chloroform  at  room  temperature,  and  then  to  a  special  animal 
mask,  using  a  Junker  inhaler  for  the  chloroform.  Gwathmey  ^  found 
that  it  took  8.92  -f-  minutes  on  the  average  to  kill  (26  animals  being 
used).  Employing  the  same  technique,  with  the  addition  of  another 
Junker  inhaler  filled  with  warm  water  and  placed  in  a  warm  receptacle 
between  the  chloroform  and  animal  mask,  it  was  found  that  the  average 

V.  Am.  Med.  Assn.,  47,  1361-64. 


CHLOROFORM  315 

time  required  to  kill  (using  17  animals)  was  20.35  minutes,  thus  show- 
ing that  chloroform  at  blood  temperature  is  three  times  as  safe  as  chloro- 
form at  room  temperature. 

Intermittent  Narcosis. — Chloroform  should  never  be  administered 
in  the  manner  sometimes  employed,  unfortunately,  with  ether,  namely,  a 
small  quantity,  then  a  pause,  and  again  a  small  quantity.  The  objection 
urged  against  the  drop  method  outlined  above  is  that  the  anesthetist  is 
occupied  every  second  of  the  time  the  patient  is  under  the  anesthetic. 
This  is,  in  reality,  one  of  the  strongest  arguments  in  its  favor,  as  any 
untoward  signs  or  symptoms  are  immediately  recognized,  and  avoidable 
accidents  are  not  encountered. 

Color  Eeflex. — If  the  anesthesia  has  been  induced  as  outlined 
above,  the  patient's  color  will  vary  according  to  the  individual.  If,  at 
any  time,  a  sudden  pallor  appears  about  the  nose  and  mouth,  it  indi- 
cates shock  from  some  cause,  or  is  a  premonitory  symptom  of  vomiting. 
If  the  latter,  this  condition  can  be  immediately  rectified  by  an  increased 
dosage.  The  anesthetist  should  touch  the  forehead  or  ear  of  the  patient 
occasionally  and  note  the  reflex;  i.  e.,  the  quickness  with  which  the  color 
returns.  This  reflex,  taken  in  consideration  with  other  signs  to  be  given 
below,  is  a  good  indication  of  the  heart's  action.  If  the  color  returns 
immediately  after  removing  the  pressure  of  the  finger,  the  heart  is  in 
good  condition.  If  this  reflex  is  very  slow  it  may  not  necessarily  indi- 
cate danger ;  but  it  would  indicate  a  weak  heart,  and  possibly  dangerous 
ground. 

The  Pupil. — If  morphin  has  been  given  as  a  preliminary  medica- 
ment, the  pupil  will  contract  as  soon  as  surgical  anesthesia  is  reached, 
and  usually  remain  so  throughout  the  operation  (this,  of  course,  will 
depend  somewhat  upon  the  action  of  the  morphin  in  that  particular 
subject).  It  is  unnecessary  to  attempt  any  observation  of  the  eye  as 
long  as  the  reflexes  are  active  and  the  patient  is  in  the  second  stage  of 
anesthesia.  If  no  preliminary  medicament  has  been  given  the  pupil  will 
be  contracted  a  little  below  normal.  If  surgical  shock  intervenes  from 
loss  of  blood,  or  handling  important  nerves  and  vessels,  or  if  too  light 
an  anesthesia  is  being  maintained,  the  pupil  may  dilate.  If  an  overdose 
of  the  anesthetic  has  been  given  the  pupil  will  also  dilate,  but  will  remain 
in  this  condition.  The  difference  between  the  dilated  pupil  of  a  light 
anesthesia  and  one  of  an  overdose  must  be  determined  immediately  by 
the  anesthetist.  This  can  be  done  by  recalling  the  amount  of  anesthetic 
that  has  been  given  within  the  last  two  or  three  minutes. 

Conjunctival  Eeflex. — In  order  to  obtain  the  conjunctival  reflex, 
place  the  index  finger  upon  the  upper  eyelid  and  gently  separate  it  from 
the  lower  lid.  Now  press  down  slightly  upon  the  upper  lid  and  bring 
the  ball  of  the  second  finger  in  contact  with  the  conjunctiva  of  the  upper 
lid  thus  exposed.    All  of  this  should  be  done  quickly.     If  the  lid  closes. 


316  ANESTHESIA 

or  if  it  remains  insensitive  when  considered  with  the  other  signs,  it  will 
indicate  whether  or  not  the  necessary  plane  of  anesthesia  is  being  main- 
tained. 

Lower  Lid  Reflex. — This  reflex  is  relied  upon  by  some  anesthetists. 
As  the  upper  lid  is  separated  from  the  lower,  a  movement  of  the  lower 
lid,  active,  slight,  or  dulled,  would  indicate  the  degree  of  narcosis. 

Eyelash  Eeflex. — This  is  obtained  by  passing  the  index  and  second 
finger  quickly  over  the  eyelash  of  either  eye. 

■Lid  Eeflex. — Many  anesthetists  merely  open  the  eye,  and  only 
deepen  the  narcosis  when  closure  ensues.  This  is  not  quite  so  sensitive 
a  sign  as  the  lower  lid  reflex. 

Eegardless  of  the  eye  reflex  used,  it  should  not  be  resorted  to  oftener 
than  twice  in  five  minutes,  or,  better  still,  once  in  five  minutes.  One 
eye  should  be  held  in  reserve,  for  if  this  sign  is  resorted  to  by  the  anes- 
thetist too  often,  the  reflex  becomes  either  too  deadened  or  too  active  to 
be  of  value. 

Pulse. — The  pulse  is  most  important  in  chloroform  anesthesia.  If 
cold  chloroform  is  administered,  a  drop  of  five  beats  a  minute  is  easily 
noted.  If  given  warmed,  as  suggested  in  this  chapter,  the  pulse  will  be 
maintained  at  a  normal  rate  (see  page  314).  If  anesthesia  is  induced 
as  indicated,  a  rise  in  the  second  stage  need  not  necessarily  be  expected. 
In  full  surgical  anesthesia  the  pulse  should  be  full  and  regular;  any 
change  in  rhythm  or  fullness  should  be  a  warning  to  the  anesthetist. 
Color  refiex  must  always  be  considered  in  connection  with  the  pulse.  If 
no  unusual  loss  of  blood  or  handling  of  important  nerves  has  taken 
place,  an  increase  in  the  volume  and  rhythm  indicates  that  the  patient  is 
regaining  consciousness,  and  is  a  call  for  an  increase  in  the  amount  of 
anesthetic.  A  running  pulse  would  indicate  shock  from  some  source;  an 
irregular  pulse  is  always  an  indication  of  danger. 

Eespiration. — The  respiration  is  to  be  more  closely  watched  than 
any  other  sign.  The  respirations  should  be  maintained  as  full  and  regu- 
lar as  possible;  shallow  respiration  indicates  vasomotor  depression,  or  it 
may  occur  just  before  vomiting,  or  as  one  of  the  signs  of  shock.  Irreg- 
ular and  shallow  breathing  may  be  caused  by  too  small  an  amount  of 
anesthetic.  It  should  be  the  anesthetist's  aim  to  keep  the  respirations 
full  and  regular.  Even  when  ether  is  contraindicated  as  the  anesthetic, 
one,  two,  or  three  drops  upon  the  mask  for  one  or  two  minutes  (at  the 
same  time  continuing  the  chloroform  administration)  is  a  good  pro- 
cedure. If  there  is  an  objection  to  this.  Farina  cologne,  or  an  occasional 
drop  of  aromatic  spirits  of  ammonia,  or  an  alcoholic  solution  of  the  oil 
of  bitter  orange  peel  (as  in  the  beginning)  may  be  tried.  The  gentle 
rubbing  of  the  lips  with  a  towel,  or  piece  of  gauze,  will  usually  stimulate 
the  respiration.  The  anesthetist  must  not  rely  upon  any  one  of  the 
above  signs,  but  must  consider  each  in  its  relation  to  the  other,  and  their 


CHLOROFORM  317 

relation  to  the  surgical  procedure  as  a  wliole.  In  this  way  only  can  the 
proper  level  of  anesthesia  be  maintained. 

From  laboratory  and  clinical  experience,  the  senior  author  has  been 
fully  convinced  for  a  number  of  years  that  the  dangers  from  chloroform 
are  reduced  to  a  minimum  so  long  as  the  respirations  are  full  and  regu- 
lar, and.  the  concentration  does  not  exceed  2  per  cent.  In  the  intentional 
killing  of  hundreds  of  animals  in  the  laboratory  we  have  failed  to  see  a 
death  from  chloroform  in  which  the  respirations  did  not  cease  before  the 
heart.  The  only  exception  to  this  rule  was  when  the  chloroform  was 
given  in  a  very  concentrated  vapor.  This  view  is  confirmed  by  Hare,^ 
who  states  that  "the  dominant  action  of  chloroform  is  certainly  upon  the 
respiratory  centers  in  the  medulla,  and  that  this  effect  is  the  cause  of 
death  in  most  cases  of  chloroform  accident.  Not  only  does  nearly  all  ex- 
perimental work  teach  us  this,  but  in  a  collective  investigation  as  to  the 
cause  of  death  under  chloroform  nearly  every  case  reported  was  found  to 
have  suffered  primarily  from  respiratory  arrest."  These  findings  were  in- 
dependently confirmed  by  Eandall  and  Cerna  in  Texas.  The  only  excep- 
tion to  this  would  be  in  cardiac  disease  of  any  kind,  when  it  can  be  easily 
understood  that  this  organ  would  be  the  first  affected.  When  we  take 
into  consideration  that  chloroform  affects  the  respiratory  centers  and,  in 
addition,  has  direct  action  upon  the  heart  itself,  and  that  there  is  also  a 
lowering  of  the  temperature  during  the  administration,  it  is  easily  under- 
stood that,  in  a  long  operation,*  all  three  of  these  factors  acting  together 
would  readily  produce  shock  of  a  serious  nature. 

Other  Methods  of  Administration. — The  best  results  have  been  ob- 
tained with  the  Eoth-Drager,  or  the  Gwathmey  three-bottle  vapor 
inhaler,  or  some  similar  apparatus,  in  which  the  percentage  of  chloro- 
form is  approximately  known,  oxygen  being  administered  conjointly  with 
the  chloroform,  and  the  vapors  being  warmed  through  rebreathing.  The 
patients  come  out  of  this  form  of  anesthesia  in  as  quiet  a  state  as  with 
nitrous  oxid  and  oxygen. 

The  Roth-Drager  Oxygen  and  Chloroform  Apparatus. — The  Eoth- 
Drager  apparatus  is  designed  to  supply  a  mixed  anesthestic  of  chloroform 
or  ether  vapor,  separately  or  combined,  in  an  atmosphere  of  oxygen.  The 
face-piece  (which  is  rigid  and  is  suitable  for  all  faces  except  the  edentu- 
lous) forms  an  additional  mixing  chamber,  as  it  admits  air  which  dilutes 
the  oxygen  and  thus  presents  an  atmosphere  richly  supplied  with  oxygen 
and  easily  respirable.  The  percentage  of  anesthetic  vapor  is  always 
known,  as  is  also  the  pressure.  The  patient  merely  breathes  to  and  fro 
into  the  face-piece,  which  is  kept  filled  w4th  the  mixed  gases.  By 
gradually  increased  doses  the  administrator  controls  the  amount  of  anes- 
thetic required  at  different  stages  of  the  operation;  if  he  desires  only 
chloroform,  he  turns  that  indicator.  If  ether  is  to  be  added  he  can  easily 
^  Bull.  Johns  Ro'pTiins  Hosp.,  Jan.,   1895. 


318 


ANESTHESIA 


do  so,  and  regulate  the  amount  of  each  as  the  patient  requires.  The 
average  induction  period  is  six  to  eight  minutes  for  adults.  It  is  seldom 
marked  by  excitement  or  struggling,  and  respiration  seems  free  and  un- 
embarrassed. The  narcosis  is  sufficiently  profound  for  all  surgical  opera- 
tions requiring  relaxation. 

The  apparatus  is  extremely  simple  to  work,  in  spite  of  its  somewhat 
formidable  appearance.  It  produces  a  satisfactory  narcosis  without  any 
period  of  struggling  or  respiratory  distress. 


Fig.  125. — The  Roth-Drager  Apparatus.     Simple  hand  apparatus. 


The  after-effects  are  usually  slight,  if  the  anesthetist  is  careful  to 
limit  the  amount  of  anesthetic  given.  It  is  clear  that  the  anesthetist  is 
enabled  to  obtain  and  maintain  an  anesthesia  which  would  be  either  dan- 
gerous or  impossible  without  the  use  of  oxygen  combined  with  the  anes- 
thetic. Vomiting  may  occur  if  too  feeble  a  vapor  is  given  during  the 
induction  period. 

The  apparatus  delivers  three  liters  of  oxygen  mixed  with  five  liters 
of  air,  which  is  the  volume  of  gas  necessary  for  the  breathing  of  an  adult, 
that  is,  eight  liters  per  minute.  The  falling  of  the  drops  of  chloroform 
or  ether  is  both  visible  and  audible.  In  this  way  a  constant  control  of 
the  working  of  the  apparatus  is  possible.  The  principal  points  of  advan- 
tage claimed  for  the  apparatus  are: 

(1)  The  color  of  the  face  does  not  alter;  (2)  the  awakening  is 
infinitely  more  easy;  (3)  irritation  of  the  bronchia  is  reduced  to  a 
minimum;  (4)  the  breathing  is  quiet  and  regular;    (5)    depression  of 


CHLOROFORM 


319 


the  pulse  does  not  occur;  (G)  the  pupils  remain  contracted;  (7)  re- 
covery takes  place  quickly  and  completely. 

Chemical  investigations  show  that  even  in  a  long  narcosis  a  decom- 
position of  the  chloroform  does  not  occur.  The  anesthetist  has  both 
hands  free  at  all  times. 

Statistics  of  the  General  Hospital  at  Liibeck  show  that  the  usual 
amount  of  chloroform  consumed  is  391/2  grams  for  a  narcosis  lasting 


Chloroform 


DRAGERWERK 
LUBECK 


tSSm^i 


Fig.  126. — The  Roth-Drager  Apparatus.     Hand  double  apparatus. 


about  40  minutes.  The  amount  of  chloroform  used  with  the  Eoth- 
Drager  apparatus  for  the  same  length  of  time  is  20  grams.  The  con- 
sumption of  oxygen  for  40  minutes  amounts  to  129  liters. 

In  Figures  125,  126,  and  127  the  parts  of  the  apparatus  are  let- 
tered as  follows:  M,  the  main  valve  of  the  oxygen  cylinder;  N",  the 
finimeter,  showing  the  quantity  of  oxygen  contained  in  the  cylinder 
at  all  times,  and  thus  rendering  a  constant  control  of  its  contents  pos- 
sible ;  0,  a  small,  easily  manipulated  valve  by  means  of  which  the  stream 
of  oxygen  can  be  quickly  turned  on  and  off;  P,  an  instrument  which 
indicates  the  number  of  liters  of  oxygen  used  per  minute ;  Q,  the  thumb- 
screw which  is  turned  to  perform  the  dosing  of  oxygen  (P  operates  in 
response  to  Q)  ;  R,  the  cock  which  controls  the  dose  of  chloroform  ad- 
ministered per  minute ;  T,  the  chloroform  in  a  removable  glass  which  is 
graduated  so  as  to  provide  a  further  means  for  ascertaining  the  quantity 
of  chloroform  used  during  each  narcosis;  V,  the  gasifier  with  observa- 


320 


ANESTHESIA 


tion  glass;  L,  the  economizing  apparatus  with  bag  I.     L  is  connected 
Avith  the  face-mask  l)y  a  metal  hose. 

The  scale  of  the  chloroform  cock  E,  is  graduated,  the  graduations 
representing  drops  per  minute  and  grams  per  minute,  so  that  the 
strength  of  the  dose  being  administered  can  be  ascertained  by  merely 
looking  at  the  position  of  the  scale.  By  turning  the  pointer  in  another 
position  any  change  in  the  strength  of  the  dose  can  be  instantaneously 
effected.    The  chloroform  reservoir  G  is  kept  in  position  by  the  arm  B. 

To  remove  the  glass  the  lever  B  is 
pressed  downward.  The  stream- 
ing of  the  oxygen  causes  suction 
in  the  glass  S.  By  this  means  the 
chloroform  is  drawn  up  through 
the  pipe.  H  and  is  caused  to  fall 
from  the  drop-former  T  drop  by 
drop.  The  drops  fall  into  the 
stream  of  oxygen,  burst  into  frag- 
ments and  vaporize.  By  turning 
the  chloroform  the  strength  of 
suction  can  be  adjusted  at  will, 
and,  if  desired,  can  be  stopped  al- 
together. 

Vernon  Harcourt's  Inhaler. — 
The  improved  Harcourt  inhaler 
provides  a  definite  mixture  of  air 
or  oxygen  with  chloroform.  A 
maximum  two  per  cent  vapor  is 
provided.  This  is  supposed  to  be 
the  most  accurate  inhaler  ever  de- 
vised for  the  administration  of  chloroform.  Two  colored  glass  beads  are 
dropped  in  the  chloroform  bottle  to  indicate  the  temperature  ranges 
between  13°  and  15°  C.  If  the  temperature  of  the  chloroform  is  below 
13°  C,  both  the  colored  beads  will  float.  If  it  is  above  15°  C,  both  will 
sink.  The  correct  temperature  is  indicated  by  the  blue  bead  sinking  and 
the  red  bead  beginning  to  sink.  A  two  per  cent  chloroform  vapor  can 
be  continuously  administered,  or  only  air  may  be  inhaled.  The  valves 
are  of  delicate  mechanism,  and  easily  moved  by  the  inspiration  and 
expiration  of  the  patient.  It  has  been  found  that  with  this  apparatus 
a  one  per  cent  vapor,  or  less,  is  sufficient  to  maintain  an  even  narcosis 
in  the  average  run  of  cases. 

Hewitt's  criticism  of  this  inhaler  is  as  follows  :i 
First:     That  the  current  through  it  depends  upon  the  respiratory 
action  of  the  patient. 

^Hewitt:    " Angesthetics, "    1912,   492. 


Fig.  127. — The  Roth-Drager  Apparatus. 


CHLOROFORM 


321 


Second:  That  the  face-piece  pressure,  whicli  is  often  necessary  in 
order  to  obtain  proper  chloroform  percentages,  will  seriously  interfere 
with  the  respiration. 

Third :  That  its  management  be- 
comes irksome  to  the  administrator, 
particularly  in  long  cases. 

Fourth :  That  it  cannot  be  used 
for  many  operations. 

Fifth :  It  cannot  be  readily  ster- 
ilized. 

Sixth :  The  disadvantage  of  mak- 
ing the  respiratory  pump  of  the  pa- 
tient act  as  the  pump  of  the  ap- 
paratus. 

From  the  fact  that  several  fatal- 
ities have  been  reported  while  using 
this  apparatus,  it  would  seem  that 
accidents  cannot  be  entirely  pre- 
vented by  accurate  chloroform  per- 
centages. A  comparison  of  this 
inhaler  with  the  Eoth-Drager  ap- 
paratus, taking  into  consideration  the 
appearance  of  the  patient  immedi- 
ately after  the  discontinuance  of  the 
narcosis,  would  compel  us  to  prefer 
the  Eoth-Drager  apparatus. 

There  is  no  provision  in  the  Ver- 
non Harcourt  inhaler  for  rebreathing.     In  addition,  no  effort  is  placed 
upon  the  respiratory  pump  by  the  Eoth-Drager  apparatus,  as  the  oxygen 


Fig.  128. — Vernon  Harcourt's  In- 
haler, Complete  with  Face  Piece, 
Bottle  and  Beads. 


FiQ.  129. — Junker's  Apparatus. 


or  air  with  chloroform  is  forced  into  the  bag  under  certain,  definite 
pressure. 


322  ANESTHESIA 

Junker  Apparatus. — This  was  the  first  vapor  ^  apparatus  devised,  and 
it  is  especially  applicable  for  adenoid  and  tonsil  work,  or  any  opera- 
tions about  the  head  where  the  anesthetist  must  constantly  change  his 
position.  The  apparatus  is  so  arranged  that  an  approximate  maximum 
of  two  per  cent  is  reached.  The  percentage  will  vary  according  to  the 
amount  and  temperature  of  ether  in  the  bottle  and  pressure  upon  the 
hand  bulb.  The  great  advantage  of  this  and  all  other  similar  inhalers 
is  that  a  continuous  narcosis  can  be  maintained  with  the  mouth  open. 
(Fig.  129.)  The  vapor  can  also  be  given  through  nasal  tubes  directly 
into  the  nares,  without  interfering  with  the  operator. 


Fig.  130. — Hewitt-Mason's  Mouth-Gag  with  Anesthetic  Tubes. 

Junker's  original  inhaler  consisted  of  a  bottle  holding  about  two 
ounces  of  chloroform;  this  bottle  was  suspended  from  the  coat  of  the 
anesthetist  by  a  hook.  A  hand-bellows  forced  air  through  a  tube  run- 
ning through  the  top  of  the  bottle  to  the  bottom ;  air  was  forced  through 
this  tube,  and,  as  it  bubbled  up  through  the  chloroform,  was  conveyed 
to  the  patient  by  another  tube  that  merely  penetrated  the  cork;  this 
latter  tube  was  fastened  either  to  a  mask  or  a  hollow  tube  or  a  nose- 
piece.  It  was  entirely  satisfactory,  provided  the  bottle  was  not  tilted, 
and  that  no  mistake  was  made  in  attaching  the  rubber  tubes  from  the 
face-piece  and  hand-bulb  to  the  tubes  entering  the  top  of  the  bottle. 
In  either  event,  liquid  chloroform  would  be  forced  into  the  upper  air 
passages.  Hewitt  made  a  decided  improvement  upon  the  Junker  inhaler 
by  making  it  impossible  for  such  an  accident  to  occur.  He  also  de- 
vised a  metal  mouth-tube  and  mouth-gag,  after  which  other  mouth- 
gags,  including  one  of  the  author's  (J.  T.  G.),  have  been  modeled. 
(Fig.  130.) 

Oxygen  may  be  passed  through  the  chloroform  by  merely  attaching 
the  tube  from  the  oxygen  tank  to  the  afferent  tube  leading  to  the  bottle. 

*  The  vapor  method  is  one  in  which  air,  oxygenated  air,  oxygen,  or  other  gas 
passes  either  over  or  through  the  drug,  thus  vaporizing  and  delivering  the  an- 
esthetic in  predetermined  percentages.  For  a  discussion  of  ether  vapor  anesthesia, 
see  Chapter  V. 


CHLOROFORM  323 

Most  of  the  bottles  now  have  compartments  for  both  chloroform  and 
ether,  so  that  the  anesthetist  can  combine  the  vapors  at  will.  'J'he  ap- 
paratus was  designed  especially  for  operations  about  the  head,  neck, 
and  upper  air  passages,  especially  operations  where  the  mouth  must  re- 
main open  for  some  length  of  time. 

Braun's  Inhaler. — Braun,  of  Leipzig,  modified  Junker's  inhaler  so 
that  either  chloroform  or  ether  alone,  or  any  combination  of  the  two 
drugs,  might  be  given.  A  metal  mask,  without  valves,  but  with  a  small 
opening  in  the  top  to  insure  the  supply  of  air,  comes  with  the  ap- 
paratus. Braun's  apparatus  originated  with  the  idea  of  giving  a  con- 
tinuous anesthesia  with  highly  attenuated  ether  vapor  to  which,  from 
time  to  time,  chloroform  is  added,  according  to  requirements;  he  thus 
secures  the  advantages  of  both  agents  and  discards  their  disadvantages. 
He  adds  only  small  amounts  of  chloroform  when  the  ether  vapor  is  in- 
sufficient to  produce  the  desired  effects.  The  Braun  apparatus  is  sim- 
ple and  easy  to  operate,  and  has  decided  advantages  over  the  Harcourt 
inhaler. 

Gwathmey  Three-Bottle  Vapor  Inhaler. — The  apparatus  is  a  modifi- 
cation of  Braun's,  with  the  addition  of  a  water  bottle,  through  which 
all  the  vapors  of  chloroform  and  ether  must  pass  before  getting  to  the 
patient.  In  addition,  in  cold  weather,  a  heater  is  used  to  warm  the 
anesthetic  to  the  temperature  of  the  blood.  With  this  apparatus  air  or 
oxygen  can  be  increased  or  decreased  without,  at  the  same  time,  de- 
creasing or  increasing  the  anesthetic  vapor.  The  apparatus  consists  of 
three  six-ounce  bottles.  In  the  ether  and  water  bottles  the  end  of  the 
tube  is  flattened  out  so  as  to  get  the  maximum  amount  of  vaporization; 
the  smaller  bottle,  containing  a  little  over  one  ounce,  is  placed  within 
the  large  six-ounce  bottle  marked  "chloroform."  The  tube  in  the  chlo- 
roform bottle  is  perfectly  straight.  It  is  estimated  that  with  the  mask 
used  a  two  per  cent  maximum  vapor  is  obtained.  Pure  ether,  chloro- 
form, or  a  mixture  of  these  anesthetics,  may  be  given  by  simply  turn- 
ing one  stopcock  on  the  top  of  the  metal  holder.     (See  p.  33.1:.) 


CHAPTER    VIII 

THE    SELECTION    OF    THE    ANESTHETIC    AND    TECHNIQUE    FOB 
SPECIAL    OPERATIONS 

Conditions  Affecting  Selection  :  Inhalation  Anesthetics ;  Safest 
Anesthetic;  Chloroform  with  Oxygen;  Value  of  Combinations  and 
Sequence  in  Anesthetics ;   Safest  Sequence. 

EuLES  to  Be  Observed  in  Selecting  the  Anesthetics:  Age; 
Heart  Disease;  Pulmonary  Tuberculosis;  Obese  Patients;  Thin  Subjects; 
Athletes,  Alcoholics,  and  Other  Drug  Habitues;  Diseases  of  the  Lungs; 
Kidney  Diseases;  Cancer;  Nervous  Patients;  Epileptics;  Insane  Pa- 
tients;  Status  Lymphaticus. 

Special  Operations  :  Short  Operations ;  Nitrous  Oxid ;  Ethyl 
Chlorid;  Chloroform  and  Ether;  The  Mastoid;  The  Upper  Respiratory 
Tract;  Excision  of  the  Tongue;  Cleft  Palate;  Submucous  Operations; 
Adenoid  and  Tonsil  Cases;  Tracheotomy;  Goiter  (Angina  Ludovici,  Ex- 
ophthalmos— Graves'  Disease)  ;  Amputations;  Operations  Upon  Fingers 
and  Toes;  Circumcision;  Rectal  Cases;  Obstetric  Cases;  Curettage; 
Genito-urinary  Operations;  Laparatomy;  Gastro-enterostomy  and  Simi- 
lar Operations ;  Peritonitis  or  Intestinal  Obstruction. 

Conclusions. 

Bibliography. 


CONDITIONS    AFFECTING    SELECTION 

In  selecting  an  anesthetic  for  a  given  operation  many  things  must  be 
considered.  First  of  all,  the  safety  to  life.  Then  the  applicability  of 
other  anesthetics  to  the  patient,  whose  size,  age,  habits  of  life,  and  con- 
dition at  the  time  of  operation  must  all  be  considered.  The  surgeon's 
likes  and  dislikes  also  demand  attention.  If  he  is  accustomed  to  using 
chloroform,  with  its  quiet  breathing  and  subdued  pulse,  he  will  not 
be  satisfied  with  ether,  with  its  quick,  bounding  pulse  and  rapid  respira- 
tion. Some  surgeons  object  seriously  to  a  patient  moving,  although  this 
movement  may  not  interfere  with  the  operation.  The  very  fact  of  the 
patient's  moving  may  cause  him  to  become  nervous  and  thus  prevent 
him  from  doing  his  best  work.    Again,  other  surgeons  like  a  light  anes- 

324 


ANESTHETIC  AND  TECHNIQUE  FOR  SPECIAL  OPERATIONS  325 

thetic,  and  those  who  have  adapted  themselves  to  nitrous  oxid  and 
oxygen  may  not  be  pleased  with  chloroform  with  its  absolute  quiet  and 
relaxation. 

Inhalation  Anesthetics. — A  list  of  anesthetics,  their  combinations 
and  sequences,  is  therefore  desirable.  The  following  list,  as  regards 
safety  to  life,  is  based  upon  original  experiments  made,  in  1904,  by 
one  of  the  authors  (J.  T.  G.)  :  1,  Nitrous  oxid  with  oxygen;  2, 
nitrous  oxid  with  air;  3,  ethyl  chlorid  with  oxygen;  4,  ethyl  chlorid 
with  air ;  5,  anesthol  with  oxygen ;  6,  ether  with  oxygen ;  7,  chloroform 
with  oxygen;  8,  ether  with  air;  9,  C.  E.  mixture  (chloroform  two  parts, 
ether  three  parts,  and  oxygen)  ;  10,  C.  E.  mixture  with  air;  11,  chloro- 
form with  air. 

Safest  Anesthetic— Nitrous  oxid  with  oxygen  is  easily  the  safest 
anesthetic  known.  It  is  almost  impossible  to  kill  normal  animals  with 
this  combination.  If  they  are  asphyxiated,  and  the  mask  is  removed, 
the  heart  will  continue  to  beat  for  several  minutes.  This  gives  suffi- 
cient time  for  the  gas  to  escape  as  it  reaches  the  lungs,  and  for  breath- 
ing to  commence  again  automatically.  Such  is  the  case  in  the  labora- 
tory and  in  the  operating  room.  The  only  likelihood  of  a  mistake  is 
when  the  physiological  signs  of  asphyxiation  are  not  known. 

Chloroform  with  Oxygen. — While  chloroform  is  classed  as  the  most 
dangerous  anesthetic,  generally  speaking,  the  purity  of  the  chemical, 
the  mode  of  administration,  and  the  environment  may  considerably 
alter  its  place  in  the  list.  If  used  with  oxygen,  and  in  definite  per- 
centages, it  is  safer  for  certain  cases  (i.  e.,  patients  with  abnormally 
narrowed  air  passages)  than  is  nitrous  oxid  with  oxygen.  Again  it  is 
safer  in  tropical  countries  and  in  the  summer  time  than  in  a  colder  cli- 
mate or  during  the  winter.  The  patient's  physique  may  be  such  that 
it  would  be  very  difficult,  if  not  impossible,  to  administer  nitrous  oxid 
with  oxygen  alone. 

Value  of  Combinations  and  Sequence  in  Anesthetics. — Again,  the 
relative  safety  of  these  anesthetics  is  enhanced  by  using  them  in  proper 
combination  and  sequence.  The  following  is  a  list  of  the  usual  com- 
binations and  sequences: 

(1)   Nitrous  oxid  with  oxygen,  combined  with  warm  ether. 

(3)   Nitrous  oxid  with  oxygen,  combined  with  ethyl  chlorid    (either 
closed  or  open). 

(3)  Nitrous  oxid-ether  sequence. 

(4)  Nitrous  oxid-ether  sequence   (closed  method),  followed  by  ether. 

(5)  Nitrous  oxid-oxygen-ether  sequence  (vapor  or  drop). 

(6)  Nitrous  oxid-ether  sequence,   followed  by  ether  and  chloroform. 

(7)  Nitrous  oxid-ethyl  chlorid-ether  sequence  (closed  method). 

(8)  Ethyl  chlorid-ether  sequence. 

(9)  Ethyl  chlorid,  ether-chloroform  sequence. 


326  .  ANESTHESIA 

(10)  C.  E.  mixture-ether  sequence. 

(11)  C.  E.  mixture-ether-chloroform  sequence. 

(12)  Chloroform  with  ether  sequence  (vapor  or  drop). 

(13)  Chloroform  ether-chloroform  sequence  (vapor  or  drop). 

(14)  Chloroform-ether    (vapor    or    drop),    followed    by    ether    (closed 

method). 

(15)  Ether-chloroform  sequence. 

(16)  Ether-chloroform-ether  sequence. 

Safest  Sequence. — The  latest  and  best  development  in  "anesthetics 
is  the  use  of  ether  and  chloroform  in  combination  with  nitrous  oxid 
with  oxygen,  making  nitrous  oxid  and  oxygen  the  basis  of  the  anes- 
thesia. It  has  also  been  found  by  clinical  experience  that  what  is  com- 
monly known  as  the  gas-ether  sequence, — that  is,  giving  first  gas  from 
one  to  two  minutes,  and  then  switching  to  ether, — is  the  best  method  of 
administering  ether  in  suitable  cases.  (See  page  218.)  The  gas-ether- 
chloroform  sequence  is  a  still  further  modification  of  the  above,  and 
for  certain  cases  it  is  probably  the  best  sequence.  ISTo  hard-and-fast 
rules  are  to  be  laid  down,  however,  for  the  selection  of  the  anesthetic, 
for  the  method  of  its  administration,  or  for  the  time  of  changing  from 
one  anesthetic  to  another.  This  must  be  learned  by  experience,  and  the 
anesthetist  must  know  the  physiological  effect  and  the  dosage  of  each 
drug  that  he  uses. 

The  fact  that  these  anesthetics  are  used  in  combination  and  se- 
quence by  the  most  expert  anesthetists  of  to-day  is  good  evidence  that 
in  many  cases  no  one  agent  is  suitable  throughout  the  anesthesia.  It 
is  unwise  to  suggest  or  recommend  this  or  that  special  anesthetic  or 
method,  as,  for  example,  ether  by  the  drop  method,  for  this  seems  like  an 
attempt  to  fit  the  anesthetic  to  the  anesthetist  rather  than  to  the  pa- 
tient. 

RULES    TO    BE    OBSERVED    IN    SELECTINCt    THE    ANESTHETIC 

Some  definite  rules  serve  to  guide  us  in  the  selection  of  a  suitable 
anesthetic. 

Age. — Infants. — Children  under  one  year  of  age  should  never  be 
kept  under  the  anesthetic  longer  than  one  hour.  Many  children  have 
been  successfully  anesthetized  for  one  or  two  hours  at  a  delicate  age,  but 
a  certain  definite  risk  is  incurred  when  the  anesthesia  lasts  one  hour  or 
more  for  a  child  under  one  year  old. 

Until  within  recent  years  it  has  been  the  custom  to  administer  chloro- 
form to  children.  A  number  of  deaths  have  been  reported  of  children 
dying  two  or  three  days  after  the  administration  of  chloroform,  and  post- 
mortem examination  has  revealed  the  fact  that  these  children  had  what 
is  known  as  status  lymphaticus.     (See  page  331.)      "The  clinical  evi- 


ANESTHETIC  AND  TECHNIQUE  FOR  SPECIAL  OPERATIONS    327 

deuces  of  this  condition  do  not  allow  its  certain  detection  beforehand, 
but  the  anesthetist  will  be  wise  to  be  particularly  on  his  guard  when  the 
patient  is  a  child  or  young  adult  of  slight  physique,  though  good 
height,  pale  complexion,  timorous  disposition,  or  with  large  tonsils  and 
adenoids.  If  the  spleen  is  palpable  and  there  are  palpably  enlarged  cervi- 
cal or  abdominal  glands,  apprehension  is  still  better  founded.  Lymphoid 
follicles  visible  on  the  epiglottis  and  much  enlarged  papillae  at  the  back 
of  the  tongue  are  also  evidences  suggestive  of  the  condition."  ^  On 
this  account  it  is  now  customary  to  administer  ether  alone  or  the  C.  E. 
mixture. 

If  chloroform  is  given  at  all  to  very  young  children,  it  should  be  ad- 
ministered warm,  and  preferably  with  oxygen  instead  of  air. 

Chloroform  should  not  be  entirely  abandoned  for  children  or  other 
subjects  because  it  has  been  misused  in  the  past.  It  is  unquestionably 
safer  and  better  to  induce  the  anesthesia  with  chloroform  in  the  majority 
of  instances  and  to  maintain  the  anesthesia  with  ether  than  to  shock  the 
child  by  attempting  to  commence  the  anesthesia  with  ether.  It  is  always 
best  to  begin  the  anesthesia  with  one  or  two  drops  of  the  essence  of  bitter 
orange  peel  (25  per  cent  TJ.  S.  P.),  or  any  cologne,  provided  it  is  not 
sweet  smelling.  Any  sweet  perfume  or  scent  tends  to  produce  vomiting 
at  this  time.  There  are  a  very  few  conditions  in  which  the  anesthesia 
should  be  maintained  with  chloroform.  Some  anesthetists  have  used 
nitrous  oxid  from  the  start  by  simply  allowing  it  to  flow  from  a  tube 
to  the  patient's  nose  and  mouth,  without  any  mask,  and  diminishing  the 
quantity  as  cyanosis  appeared.  Crying  children  are  easily  and  quickly 
anesthetized,  and  for  this  reason  should  not  be  given  chloroform  at  all. 

Nitrous  oxid,  unless  given  by  some  open  method,  is  a  very  poor  anes- 
thetic for  young  children,  as  they  do  not  seem  to  be  equal  to  the  task  of 
breathing  through  valves. 

Ethyl  chlorid  is  preferred  by  many  anesthetists  for  young  children. 
They  usually  succumb  rapidly  and  without  struggling  or  cyanosis. 

Infants  should  preferably  be  anesthetized  in  the  mother's  or  nurse's 
arms.  The  method  should  be  the  same  as  for  sleeping  children.^  Care 
should  be  taken  in  anesthetizing  children  to  make  the  operation  as  in- 
formal as  possible.  Mental  suggestion  here  plays  a  great  part,  as  well  as 
gentleness  in  voice  and  movement.  Questions  such  as  "How  old  are 
you  ?"  or  "What  is  your  name  ?"  and  immediately  calling  the  child  by  the 
first  name,  put  them  at  their  ease  at  once.  Avoidance  of  all  appearance 
of  restraint  is  necessary.  Where  a  child  is  obstinate  or  terrified  it  is 
best  to  induce  unconsciousness  as  rapidly  as  possible.  Such  children 
must  be  firmly  restrained  until  this  is  accomplished. 

^Latham  A.,  and  English,  T.  Crisp:     "A  System  of  Treatment,"  3,  25. 
-  See   article   on   Alexander 's   and   Gwathmey  's   ' '  Technique    in   Adenoid   and 
Tonsil   Operations. ' ' 


328  ANESTHESIA 

Children  Five  to  Eight  or  Ten  Years  of  Age. — The  anesthesia 
should  be  commenced  with  some  perfume  and  continued  by  the  drop 
method  of  chloroform  or  anesthol  until  the  third  stage  is  reached;  then 
the  second  mask  should  take  the  place  of  the  first  and  the  anesthesia 
should  be  deepened  and  maintained  by  ether.  This  is  the  best  method  to 
use.  English  authorities  recommend  the  C.  E.  mixture.  The  poison- 
ous effects  of  chloroform  in  connection  with  status  lymphaticus  need  not 
be  feared  when  chloroform  is  used  in  this  way.  Children  under  five  years 
of  age  should  not  be  kept  under  full  surgical  anesthesia  more  than  two 
hours. 

Ten  to  Nineteen  Years  of  Age. — The  best  anesthetic  for  young 
people  is  a  Judicious  combination  of  chloroform  and  ether  given  by  the 
.vapor  or  drop  method.  No  preliminary  medication  is  usually  necessary. 
In  some  cases,  however,  morphin  and  atropin,  in  small  quantities,  can  be 
used  to  advantage  to  prevent  excessive  flow  of  mucus.  One-twentieth  to 
one-twelfth  of  a  grain  of  sulphate  of  morphin,  with  1/300  of  a  grain  of 
atropin,  is  the  usual  dose. 

Nineteen  to  Fifty  Years  of  Age. — Nitrous  oxid  and  oxygen,  the 
gas-ether,  chloroform  or  anesthol-ether,  or  ethyl  chlorid-ether  sequences 
are  probably  the  best  agents  for  patients  from  19  to  50  years  of  age. 
Preliminary  medication  for  this  class  of  patients  must  be  considered  as  a 
part  of  the  general  anesthetic.  It  should  be  varied  according  to  the  size 
and  condition  of  the  patient.  One-eighth  to  one-quarter  of  a  grain  of 
morphin,  with  1/150  grain  of  atropin,  can  usually  be  given  with  very 
great  advantage. 

Fifty  and  Over. — Elderly  people  yield  more  readily  than  do  younger 
subjects  to  the  combination  of  chloroform  and  ether  by  the  vapor  or 
drop  method.  The  closed  method  or  the  gas-ether  sequence  is  usually 
contraindicated.  When  atheromatous  conditions  are  present,  or  cerebral 
hemorrhage  from  any  cause  is  feared,  ether  is  contraindicated,  as  is  also 
nitrous  oxid  with  oxygen.  Chloroform  with  oxygen  should  be  used  in 
these  cases.  Weak,  anemic  men  and  middle-aged  women  yield  better  to 
nitrous  oxid  with  oxygen,  either  alone  or  supplemented  by  small  amounts 
of  ether  and  chloroform. 

Many  of  these  patients  have  some  respiratory  trouble,  as  chronic 
bronchitis  or  asthma,  or  arteriosclerosis.  There  is  very  little  fear  of 
chloroform  poisoning  in  the  aged,  and  yet  it  is  always  best  to  supplement 
chloroform  by  ether  in  sufficient  quantity  at  least  to  maintain  a  good 
type  of  respiration  throughout  the  anesthesia.  Care  should  be  taken  to 
avoid  the  slightest  cyanosis.  Elderly  patients  are,  as  a  rule,  good  sub- 
jects for  anesthetization,  not  only  in  inducing  and  maintaining  the  anes- 
thesia, but  also  as  regards  after-effects. 

Heart  Disease. — Unless  some  definite  signs,  such  as  swollen  ankles, 
pulmonary  edema,  or  dyspnea,  are  present,  it  is  unnecessary  to  pay  atten- 


ANESTHETIC  AND  TECHNIQUE  FOR  SPECIAL  OPERATIONS    329 

tion  to  any  heart  lesion.  An  open  method  is  usually  hest  in  these  cases, 
anesthesia  being  induced  with  chloroform,  the  chloroform-ether  mixture 
or  anesthol,  and  continued  with  ether  and  oxygen.  If  loss  of  compensa- 
tion is  present,  as  indicated  by  any  of  the  above  signs,  pulmonary  anes- 
thesia should  be  avoided  and  local  or  spinal  anesthasia  used.  A  preliini- 
nary  dose  of  morphin  may  be  used  to  advantage  in  these  cases.  A  deep 
anesthesia  is  preferable  to  a  light  one.  For  paracentesis  of  the  peri- 
cardium, nitrous  oxid  with  oxygen  is  preferable. 

Pulmonary  Tuberculosis. — Patients  with  tuberculosis  should  have 
nitrous  oxid  and  oxygen  Avhenever  possible.  Ether  is  contraindicated, 
as  it  is  liable  to  light  up  a  diseased  lung  that  may  have  been  in  a  quies- 
cent stage  for  some  time.  Warmed  chloroform  and  oxygen  is  the  second 
choice. 

Obese  Patients. — As  a  general  rule  a  healthy  obese  patient  seems  to 
be  immune  to  any  poisonous  after-effects  from  chloroform.  Obese  pa- 
tients and  those  with  obstructed  or  narrowed  passages  are  best  anes- 
thetized by  warm  chloroform  and  oxygen.  Any  closed  method  should 
be  avoided  with  these  patients. 

Thin  Subjects. — With  thin,  anemic  individuals  all  other  anesthetics 
should  be  considered  before  using  chloroform,  anesthol,  or  ethyl  chlorid. 

Athletes,  Alcoholics,  and  Other  Drug  Habitues. — Athletes  and  per- 
sons addicted  to  the  excessive  use  of  alcoholic  stimulants  should  always 
receive  preliminary  medication,  regardless  of  the  anesthetic  selected. 
Morphin,  with  atropin  or  some  other  appropriate  drugs,  may  be  employed. 
For  alcoholics,  especially,  if  one  to  two  ounces  of  whiskey  in  eight  ounces 
of  saline  solution  is  administered  per  rectum,  in  combination  with  mor- 
phin given  hypodermically,  the  anesthetic  acts  more  satisfactorily  than 
when  alcohol  is  withheld.  Persons  addicted  to  the  use  of  drugs,  such  as 
morphin,  etc.,  should  not  be  restricted  before  the  anesthetic  in  the  use 
of  the  particular  drug  concerned,  biit  should  be  given  the  dose  to  Avhich 
they  are  accustomed.  The  immediate  ill  results  of  withholding  drugs  at 
this  time  are  easily  recognizable,  but  the  opportunity  for  its  final  dis- 
continuance is  apparent. 

The  requisite  preliminary  medication  having  been  given,  the  vaj^or 
and  drop  method  of  anesthesia  is  preferable  to  any  closed  method,  as 
these  patients  suffer  especially  from  deprivation  of  oxygen. 

According  to  Mahoney,^  alcoholic  subjects  do  better  with  treatment 
for  a  week  or  ten  days  with  bromids,  with  the  gradual  withdrawal  of 
alcohol.    Treatment  for  even  a  few  days  is  better  than  none. 

Diseases  of  the  Lungs. — In  pleurisy,  empyema,  abscess  of  the  lung, 
and  in  all  operations  in  which  one  lung  is  involved,  the  patient  should 
lie  with  the  diseased  lung  lower,  in  order  to  assist  drainage  and  reduce 

^  Mahoney,  Daniel  F. :  "Some  Considerations  of  Ether  Anesthesia."  Boston 
Med.  and  Surg.  J.,  Oct.  19,  1911. 


330  ANESTHESIA- 

the  chance  of  infecting  the  healthy  lung,  and  also  to  allow  the  healthy 
lung  perfectly  free  respiratory  action. 

If  pneumonia  is  present  and  an  operation  is  absolutely  necessary,  lo- 
cal, spinal,  or  rectal  should  be  preferred  before  pulmonary  anesthesia. 

In  dyspnea' a,  local,  spinal,  or  rectal  anesthesia  is  jDreferable  to  a  pul- 
monary anesthetic.  If,  however,  a  pulmonary  anesthetic  is  used,  chloro- 
form with  oxygen  is  the  first  choice,  the  patient  being  allowed  to  assume 
the  attitude  in  which  it  is  easiest  for  him  to  breathe. 

In  acute  or  chronic  bronchitis  or  phthisis,  asthma,  pneumonia  or  any 
diseases  of  the  respiratory  passages,  ether  is,  if  possible,  to  be  avoided, 
even  with  the  most  improved  methods  of  administration.  Oxygen  and 
chloroform  or  nitrous  oxid  and  oxygen  are  the  anesthetics  to  be  chosen. 
Morphin  or  some  similar  medication  should  always  be  used .  in  these 
cases. 

Kidney  Diseases. — In  all  kidney  diseases  ether  and  chloroform  are 
usually  contraindicated.  Nitrous  oxid  with  oxygen  is  the  anesthetic  to 
be  preferred. 

In  cases  of  diabetes  in  which  sugar  is  either  absent  from  the  urine 
or  present  only  to  a  slight  degree,  chloroform  with  oxygen  anesthesia  is 
unattended  by  risk,  but  when  the  quantity  is  abnormally  large  there  is 
danger  of  diabetic  coma.  Chloroform  should  be  avoided  in  these  cases, 
and  nitrous  oxid  and  oxygen  chosen  as  the  anesthetic.  These  j)atients 
should  be  carefully  dieted  in  order  to  reduce  the  amount  of  sugar  to  the 
minimum.  Before  regaining  consciousness  they  may  relapse  into  a  coma- 
tose condition  and  die  from  acetonemia.  (For  a  discussion  of  aceto- 
nemia, see  Chapter  IX.) 

Cancer. — Wherever  the  cachectic  condition  that  is  usually  associated 
with  advanced  cancer  exists,  the  patient  takes  kindly  to  the  anesthetic 
and  requires  very  little  of  it  to  maintain  surgical  anesthesia.  These  pa- 
tients should ,  always  be  given  a  preliminary  dose  of  morphin  before 
going  to  the  operating  table,  as  many  of  them  have  been  accustomed  to 
this  medication.  Eor  removal  of  a  cancerous  breast,  nitrous  oxid  and 
oxygen  for  elderly  people,  and  ether  and  oxygen  by  the  vapor  method 
in  younger  subjects,  are  preferable,  as  the  anesthetist  is  out  of  the  way 
and  shock  is  less  liable  to  occur  than  with  other  procedures.  Chloroform 
may  be  sparingly  used  in  connection  with  the  ether.  It  is  best  to  antici- 
pate shock  in  these  cases  by  giving  one  pint  of  saline  with  one  ounce  of 
glucose  per  rectum  two  hours  before  the  operation.  Fifteen  to  twenty 
miniites  before  any  operation  is  concluded  a  pint  of  saline  with  three  or 
four  ounces  of  glucose  should  be  given  per  rectum. 

Nervous  Patients. — Nervous  patients  shoiild  be  gotten  under  the 
anesthetic  as  quickly  as  possible.  The  gas-ether  sequence  or  nitrous  oxid 
should  be  used.     This  prevents  hysterical  symptoms  from  appearing. 

Epileptics. — A  preliminary  of  morphin  is  indicated  for  this  special 


ANESTHETIC  AND  TECHNIQUE  FOR  SPECIAL  OPERATIONS    331 

class  of  patients  and  the  anesthetic  induced  with  chloroform,  with  a 
switch  to  ether  in  the  second  stage.  The  anesthetist  must  be  ready  to 
prop  a  mouth  gag  between  the  teeth  if  a  seizure  should  occur  as  the 
patient  is  going  under  the  anesthetic.  The  prop  should  be  inserted  be- 
tween the  teeth  as  the  patient  is  recovering.  It  is  usually  well  to  give  a 
small  hypodermic  toward  the  close  of  the  operation,  as  this  will  prevent 
a  later  seizure  occurring. 

Insane  Patients. — Insane  patients  should  always  Iiave  a  preliminary 
medication  of  morphin  %  of  a  grain  one  hour  before  the  operation,  to 
be  repeated,  with  1/150  grain  of  atropin,  one-half  hour  before  the  anes- 
thetic is  commenced.  The  anesthesia  should  be  induced  with  chloroform 
.  and  maintained  with  ether  and  oxygen  by  the  vapor  method.  Mental 
aberrations  have  been  known  to  occur  after  the  inhalation  of  any  or  all 
pulmonary  anesthetics.  This  is  probably  caused  by  irregular  or  inter- 
mittent narcosis. 

Status  Lymphaticus. — Definition. — Status  lymphaticus  or  thymi- 
cus,  or  lymphatism,  is  a  condition  of  infancy  and  childhood,  marked  by 
hyperplasia  of  the  lymphatic  structures,  spleen  and  bone  marrow,  and 
persistence  of  the  thymus  gland  (Stedman).  It  has  also  been  defined  as 
a  condition  of  unstable  equilibrium,  coma,  convulsions,  and  vomiting 
accompanying  hyperplasia  of  the  persisting  thymus  (Gould)  ;  and  as  a 
morbid  state  due  to  excessive  production  or  growth  of  lymphoid  tissues, 
such  as  the  thymus  and  thyroid  glands,  resulting  in  impaired  develop- 
ment, lowered  vitality,  and  sometimes  death  (Borland). 

History. — As  early  as  1614  attention  was  called  by  Felix  Plater  to 
the  fact  that  the  thymus  was  enlarged  in  three  cases  of  sudden  death 
from  dyspnea  in  one  family.  In  1823,  and  again  in  1829,  Kopp  men- 
tioned the  association  of  the  enlargement  of  the  thymus  gland  with  sud- 
den death.  Paltauf,  in  1889  and  1890,  collected,  for  the  first  time,  a 
large  number  of  cases  of  sudden  death  in  adults,  in  which  there  was 
enlargement  of  the  tonsils,  lymphatic  gland  system,  the  follicles  at  the 
base  of  the  tongue,  the  spleen,  and  the  thymus  gland,  with  narrowing 
of  the  aorta.  Kundrat,  in  1895,  published  ten  cases  of  death  immediately 
after  anesthesia  by  chloroform  or  some  mixture  containing  it,  also  one 
case  in  which  ether  was  the  anesthetic.  Sudden  deaths  were  noted  after 
this  time  in  many  cases  in  which  no  anesthetics  had  been  administered. 
Lymphatic  hyperplasia  has  been  found  to  occur  in  every  chloroform 
fatality  for  the  past  twenty  years  in  the  children's  clinic  at  Gratz.  The 
first  case  recorded  in  England  was  reported  by  Wolff  in  1905.  Two 
deaths  under  local  anesthesia  have  been  recorded  by  Horoszkiewicz. 

Anatomy.^ — "The  thymus  gland  is  a  temporary  organ  attaining  its 
full  size  at  the  end  of  the  second  year,  when  it  ceases  to  grow  and  re- 
mains practically  stationary  until  puberty,  at  which  period  it  rapidly 

^Gray:      "Anatomy/'  1442. 


332  ANESTHESIA 

degenerates.  It  does  not  entirely  disappear,  for  the  shrunken  and  de- 
generate mass  even  in  later  life  maintains  a  likeness  to  the  original  form 
and  retains  within  its  substance  small  portions  of  thymus  tissue  (Wal- 
deyer).  If  examined  when  its  growth  is  most  active,  it  will  be  found  to 
consist  of  two  lateral  lobes  placed  in  close  contact  along  the  middle  line, 
situated  partly  in  the  superior  mediastinum,  partly  in  the  neck,  and  ex- 
tending from  the  level  of  the  fourth  costal  cartilage  upward  as  high  as 
the  lower  border  of  the  thyroid  gland.  It  is  covered  by  the  sternum 
and  by  the  origins  of  the  sternohyoid  and  sternothyroid  muscles.  Below, 
it  rests  upon  the  pericardium,  being  separated  from  the  arch  of  the  aorta 
and  great  vessels  by  a  layer  of  fascia.  In  the  neck,  it  lies  on  the  front 
and  sides  of  the  trachea,  behind  the  sternohyoid  and  sternothyroid 
muscles.  The  two  lobes  generally  differ  in  size;  they  are  usually  con- 
nected so  as  to  form  a  single  mass  but  are  sometimes  separated  by  an 
immediate  lobe.  The  thymus  is  of  a  pinkish  gray  color  and  is  lobulated 
on  its  surfaces." 

Diagnosis. — The  majority  of  writers  are  agreed  that  a  positive  diag- 
nosis of  this  condition  during  life  is  very  difficult.  The  fact  is  that  en- 
larged tonsils  and  the  conditions  termed  status  lymphaticus  by  most 
writers  call  for  the  extirpation  of  the  tonsils  with  the  idea  of  increasing 
oxygen  in  the  tissues  and  the  blood,  and  stimulating  the  growth  of 
the  individual.  Connor  ^  says :  "The  plainest  sign  of  congenital 
hyperplasia  of  the  vascular  system  is  the  noticeably  small  size  and  thin 
walls  of  all  arteries." 

Pasty  complexion,  a  large  amount  of  subcutaneous  fat,  and,  in 
adults,  a  scant  amount  of  axillary  or  pubic  hair  are  usual;  also  the  hair 
of  the  head  has  a  peculiar  dry,  brittle  character.  Enlargement  of  the 
faucial,  pharyngeal,  and  laryngeal  tonsils  is  frequently  present.  The 
diagnosis  of  a  tumor  running  under  the  sternum  would  be  almost  pathog- 
nomonic of  this  condition.  Cocks  "  considers  the  X-ray  examination  sec- 
ond only  to  the  general  condition  of  the  patient  in  making  a  diagnosis. 

Most  patients  dying  during  or  immediately  after  anesthesia  have 
been  young  people  or  children,  of  flabby  type,  with  enlarged  adenoids, 
tonsils,  thyroid  (usually),  and  thymus;  with  narrow,  high-arched  palate, 
small  mouth  and  throat,  and  weak  heart  sounds.  During  anesthesia  a 
grayness  of  complexion  or  pallor  is  witnessed,  with  weak  heart  action  and 
shallow  breathing.  Enlargement  of  the  thyroid  is  said  to  exist  in  more 
than  50  per  cent  of  cases.  Enlargement  of  the  tongue  is  an  important 
factor  in  diagnosis.  The  spleen  has  been  found  to  be  greatly  enlarged  in 
many  cases,  also  the  mesenteric,  popliteal,  axillary,  and  inguinal  glands. 
Exophthalmic  goiter  may  also  be  present,  in  which  event  heart  failure 

^Connor:     N.  Y.  State  J.  Med.,  1906,  282-284. 

^  Cocks :     "A  Contribution  to  the  Pathology  and  Clinical  Diagnosis  of  Status 
Lymphaticus,"  read  before  the  Am.  Laryn.,  Rhinol.,  and  Otol.  Soc,  May,  1912. 


ANESTHETIC  AND  TECHNIQUE  FOR  SFKCIAL  OPERATIONS    333 

under  the  anesthetic  is  probable.  Congenital  defects  such  as  cIciFt  palate 
and  cleft  kidney  are  sometimes  associated  with  status  lympliaticns.  All 
patients  have  a  pale,  thin  skin,  pasty  complexion,  and  usually  subcu- 
taneous fat.  The  glands  of  the  neck  are  also  sometimes  enlarged.  The 
above  complex  symptoms  are  noted  when,  given  chloroform  for  any 
length,  of  time,  much  of  the  anesthetic  is  absorbed  and  less  secreted  than 
is  usual,  with  a  consequent  continual  poisoning  of  the  system  until  death 
occurs  several  days  after  the  anesthetic.  Sometimes  delayed  chloroform 
poisoning  is  mistaken  for  status  lymphaticus.  In  status  lymphaticus, 
especially  in  children,  patients  seem  to  dread  the  anesthetic  more  than 
is  usually  the  case.  This  fear  would  certainly  add  to  the  shock  and 
decrease  the  normal  resisting  force  of  all  the  organs  to  the  effects 
of  the  anesthetic.  Two  cases  of  death,  noted  by  Wheelock,^  at 
Fort  Wayne,  were  due  to  cardiac  failure  and  asphyxiation.  In  cardiac 
failure  no  premonitory  symptoms  are  present,  but  in  asphyxiation  there 
is  a  disturbance  of  breathing  at  various  times.  An  enlarged  thymus  has 
sometimes  produced  pressure 'from  which  asphyxial  symptoms  have  de- 
veloped. In  some  of  the  reported  cases,  death  occurring  during  anes- 
thesia always  came  suddenly,  with  pallor  and  dilated  pupils.  In  some 
there  were  superficial  respiration  and  intermittent  pulse  just  before  the 
last  signs  mentioned,  together  with  cyanosis  and  dyspnea.  Ohlmacher  ^ 
states  that  deaths  from  status  lymphaticus  are  due  to  increased  intra- 
cranial pressure,  with  sudden  edema.  Halstead  ^  points  out  the  great 
danger  of  operating  for  adenoids  and  tonsils  upon  children  with  status 
lymphaticus,  on  account  of  the  great  shock  which  the  added  fright  and 
violent  struggling  would  bring  on — in  some  cases- enough  to  produce 
death. 

Choice  of  the  Anesthetic  for  Suspected  Cases. — From  the  study 
of  a  large  number  of  statistics,  the  fact  that  chloroform  is  contraindi- 
cated  cannot  be  questioned.  Eoberts  ^  concludes  that  ether  is  the  safest 
anesthetic  for  all  of  these  cases.  Unquestionably  chloroform  should  be 
avoided  in  all  suspected  cases.  Ether  by  the  vapor  or  drop  method 
should  be  the  anesthetic  of  choice.  Ko  closed  method  should  be  used 
on  account  of  the  possibility  of  pressure  symptoms.  Children  who  sink 
into  deep  anesthesia  quickly  from  small  doses  of  the  drug  should  at  once 
be  considered  questionable  cases  for  the  anesthetist. 

Peepaeation  for  Operation. — Great  precaution  should  be  taken 
that  the  preparation  and  preliminary  medication  be  complete,  so  that 
whatever  is  given,  when  the  time  for  operation  arrives,  the  patient 
will  be  in  a  more  or  less  drowsy  condition  and  indifferent  to  the  anes- 

1  Toledo  Med.  and  Surg.  Sep.,   1909,  35,  395-399. 

2  J.  Am.  Med.  Assn.,  Feb.,  1904,  4S,  No.  7. 
sPhila.  Med.  J.,  Nov.   3,   1900. 

4  Trans.  Am.  Laryn.,  Eliinol.  and  Otol.  Sac,  St.  Louis,   1908,   507-524. 


334 


ANESTHESIA 


thetic.     (See  Chapter  IX,  Treatment^  Preliminary,  Dwing,  and  After 
Anesthesia,  p.  365;  also  Acetonemia. 

Treatment  During  Anesthesia, — If  sudden  syncope  occurs,  mas- 
sage of  the  heart,  in  connection  with  artificial  respiration,  should  be  insti- 
tuted immediately.  Hilliard  ^  thinks  that  the  hypodermic  injection 
of  morphin  and  atropin  before  the  administration  of  the  anesthetic 
is  of  great  value,  and  that,  with  this  addition,  general  anesthesia  is 
safer  than  local  anesthesia. 


Fig.  131. 


-The  Gwathmey  Three-Bottle  Vapor  Inhaler,  Mouth  Gag,  with  Hollow 
Tubes  Attached.     (See  page  323.) 


Mortality. — Harvey  Hilliard  ^  gives  a  very  complete  history  of  a 
fatal  case  of  status  lymphaticus  in  a  young  man  aged  twenty-one,  six  feet 
two  inches  in  height,  very  thin,  and  of  a  highly  neurotic  temperament. 
Operation :   circumcision. 

The  patient  was  a  great  smoker  of  cigarettes  and  subject  to  attacks 
of  faintness.  The  patient  had  the  usual  preparation,  but  was  allowed  to 
smoke  during  the  morning,  the  operation  being  at  twelve  o'clock.  Hil- 
liard found  on  examination  a  rapid  pulse,  poor  chest  expansion,  and  con- 
siderable enlargement  of  the  thyroid  gland.  Chloroform-ether  mixture 
was  the  anesthetic.  During  the  induction  period,  the  heart  beat  very  vio- 
lently. A  light  anesthesia  was  maintained.  When  the  prepuce  was 
severed,  the  patient  turned  an  ashen  color  and  stopped  breathing.  Khyth- 
mic  tongue  traction  was  employed  and  amyl  nitrite  vapor,  the  adminis- 
trator pressing  the  lower  ribs  to  restore  respiration.  This  brought  the 
patient  round.  The  anesthetic  was  discontinued  with  the  idea  of  dis- 
continuing the  operation,  when  the  patient  immediately  stopped  breath- 
ing. The  usual  restorative  methods  were  resorted  to,  but  proved  unavail- 
ing. Artificial  respiration  was  kept  up  for  forty-five  minutes,  but  the 
patient  did  not  again  come  around. 

1  Hilliard,  Harvey :  "A  Fatal  Case  of  Status  Lymphaticus, ' '  Brit,  Med.  J., 
Jan.  25,  1908,  202. 

2  Idem :     Loc.  cit. 


ANESTHETIC  AND  TECHNIQUE  FOR  SPECIAL  OPERATIONS    335 

Post-mortem  examination  sliowed  the  thyroid  gland  enlarged,  with 
degenerated  changes.  The  thymus  gland  was  persistent  and  weighed 
24  grams.     The  heart  was  dilated,  with  thin,  flahby  walls. 

In  thirty-five  cases  reported  by  McCardie  the  average  age  was  six- 
teen years,  the  youngest  patient  being  six  months ;  seven  were  under  ten 
years  of  age,  fourteen  between  the  ages  of  ten  and  twenty,  eight  from 
twenty  to  thirty,  and  two  from  thirty-one  to  thirty-two,  the  oldest  being 
fifty-five  years.     There  was  no  distinction  as  regards  sex. 

Cocks  ^  reports  forty-six  cases  of  status  lymphaticus  in  approximately 
sixteen  hundred  autopsies  at  the  Bellevue  Hospital  Pathological  Depart- 
ment. 

In  thirty  cases  examined  by  McCardie  for  status  lymphaticus  the 
deaths  during  or  after  anesthesia  were:  seventeen  from  chloroform,  six 
from  ether,  five  from  a  mixture  of  chloroform  and  ether,  and  two  doubt- 
ful cases,  in  which  the  anesthetic  was  nitrous  oxid.  There  is  also  re- 
corded the  death  of  an  infant,  one  year  old,  after  an  injection  of  1/13 
of  a  grain  of  morphin,  in  whom  post-mortem  examination  revealed  the 
signs  of  status  lymphaticus.  Two  deaths  are  reported  under  local  anes- 
thesia, both  patients  being  women,  aged  thirty  and  thirty-one  years, 
respectively. 

Death  from  any  cause,  and  especially  during  the  anesthesia,  is  always 
very  sudden.  In  rare  instances  the  enlarged  thymus  gland  may  com- 
press the  trachea  sufficiently  to  cause  death  by  suffocation.  Toxemia  in- 
duced by  the  thymus  may  reduce  the  subject  to  such  a  degree  that  sud- 
den shock  may  cause  death,  toxemia  being  primarily  responsible.  Pa- 
tients have  also  been  known  to  die  from  such  a  trivial  shock  as  bathing. 

PosT-MoRTEM  Examination. — Autopsy  usually  showed  adenoids  and 
tonsils  enlarged,  thymus  gland  very  large,  and  spleen  also  enlarged; 
heart  and  liver  healthy.  The  aorta  and  small  arteries  were  smaller  and 
thinner  than  normal,  with  signs  of  cardiac  dilatation,  evidence  of  recent 
rickets,  and  sometimes  incomplete  development  of  the  sexual  organs.  In 
some  cases  fatty  degeneration  of  liver  (principally),  kidneys,  heart  and 
other  muscles  was  noted.  Hyperplasia  of  the  lymphatic  glands  is  usually 
noted,  also  evidence  of  infantilism,  such  as,  for  example,  scanty  pubic  or 
axillary  hair.  Exophthalmic  goiter  is  frequently  associated  with  status 
lymphaticus.  Cocks  reports  over  fifteen  deaths  occurring  in  connection 
with  cerebrospinal  meningitis. 

Observation  Upon  Animals. — Oifergeld  and  Miiller  ^  have  made 
a  number  of  interesting  experimental  narcoses  upon  animals  with  the 
following  results  (presumably  with  chloroform  at  room  temperature  in 
all  cases  and  without  oxygen  except  as  stated)  : 

*  Cocks:     Loc.  cit. 

-  Offergeld  and  Miiller :  ' '  Experinienteller  Beitrag  z.  toxischen  Wirkung  des 
Chloroforms  auf  die  Nieren,"  Arch.  f.  Min.  CUr.,  1905,  75,  758. 


336  ANESTHESIA 

Animals  chloroformed  for  two  hours,  after  recovery  from  the  immedi- 
ate effects  of  the  anesthetic,  usually  died  from  48  to  60  hours  afterward; 
post-mortem  examination  showing  parenchymatous  degeneration  of  the 
heart,  liver,  and  kidneys.  When  artificial  nephritis  was  produced,  exten- 
sive injury  occurred  even  with  a  fifteen-minute  anesthesia.  When  injured 
by  mineral  acid,  pus,  germs,  or  the  injection  of  diphtheria  toxins,  it  was 
found  that  the  kidneys  were  usually  affected  by  chloroform  narcosis. 
When  pregnant  animals  were  used,  this  fact  in  itself  did  not  favor  fatty 
degeneration  unless  complicated  with  kidney  lesions.  A  second  chlorq- 
formization  favored  greatly  the  degenerated  changes  in  the  kidneys.  Fat 
seemed  to  disappear  in  the  tissues  and  to  accumulate  in  the  liver.  Offer- 
geld  concluded  that  anemic  and  cachectic  conditions  of  the  patient  fa- 
vored the  poisonous  action  of  chloroform,  and  he  warned  against  the 
danger  of  repeated  chloroform  anesthesias.  He  also  Relieved  that  the 
prevention  of  the  ill  effects  of  chloroform  might  he  accomplished  by  a 
mixture  of  chloroform  and  oxygen. 

]\Iiiller  concluded  that  the  changes  in  the  internal  organs  always 
appeared  first  as  fatty  changes,  depending  upon  the  time  and  number  of 
the  anesthesias ;  that  these  changes  were  in  direct  proportion  to  the  anes- 
thetic power  of  the  agent  used ;  that  they  usually  disappeared  after  anes- 
thesia; that  a  second  anesthesia  was  always  very  dangerous;  that  the 
fatty  changes  following  the  second  anesthesia  were  twice  as  severe  as 
from  the  first,  regardless  of  the  time  given;  that  the  second  anesthesia 
should  never  be  given  for  at  least  three  days  after  the  first;  that  pneu- 
monias occurred  frequently  with  ether;  that  chloroform  should  be  the 
second  anesthetic;  that  mixed  anesthesias  did  not  prevent  these  fatty 
changes;  and  that  these  changes  took  place  in  the  vessel  walls  of  the 
brain  as  well  as  of  the  other  internal  organs. 

Bandler's  ^  experiments  seem  to  show  that  ether  does  not  produce  the 
changes  in  the  liver  cells  caused  by  chloroform. 

Strassmann  ^  chloroformed  animals  previously  weakened  Ijy  loss  of 
blood,  with  a  greater  resulting  fatty  degeneration  than  upon  normal  ani- 
mals. 

The  senior  author  (J.  T.  G.)  agrees  with  Henderson  "  that  unskillful 
anesthesia  is  more  often  the  cause  of  death,  and  especially  in  adenoid  and 
tonsil  cases,  than  the  status  lymphaticus  or  heart  disease.  Henderson 
states  that  "writers  assume  that  status  lymphaticus  was  the  cause  of 
death,  although  there  may  have  been  no  autopsy.  Even  in  those  cases 
in  which  an  autopsy  was  performed,  the  pathologist's  report  sometimes 

^ ' '  Ueber  den  Einfluss  der  Chloroform  und  Aethernarkose  auf  die  Lieber, ' ' 
Mittlg.  aus  den  Grenzgeieit.  der  Med.,  1896,  1,  30.3. 

""VircTiow's  Arch.,  1899,  115,  1. 

^Henderson,  Yandell:  "Primary  Heart  Failure  in  Normal  Subjects  Under 
Ether,"  Surg.  Gyn.  and  Obstet.,  Aug.,   1911.  ■'' 


ANESTHETIC  AND  TECHNIQUE  FOR  SPECIAL  Oi'ERATIONS    337 

indicates  that  if  he  had  not  been  told  what  to'  find  he  wo uhl  scarcely 
have  found  it. 

"On  looking  up  the  general  subject  of  status  lyraphaticus,  I  find  that 
this  mysterious  (I  might  almost  say  mystical)  condition  was  only  a  few 
years  ago  used  in  precisely  the  same  way,  and  with  the  same  confidence,  to 
explain  another  class  of  fatalities.  It  is  less  than  a  decade  since  the 
time  when,  if  a  patient  died  suddenly  after  an  injection  of  antitoxic 
serum,  an  unsuspected  condition  of  status  lymphaticus  was  invoked  as 
the  explanation.  In  many  of  the  very  best  text-books  of  pharmacolog)' 
(written,  by  the  way,  by  laboratory  men),  the  practice  of  occasionally 
interrupting  the  administration  of  ether,  and  of  allowing  the  patient  to 
come  for  a  few  moments  pretty  well  out  of  anesthesia,  is  expressly  recom- 
mended. If  anesthetists  will  only  realize  that  this  is  a  procedure  which, 
above  all  others,  should  be  shunned,  the  number  of  cases  of  so-called 
status  lymphaticus  fatalities,  under  anesthesia,  will,  I  believe,  show  a 
sudden  and  marked  decrease." 

Henderson  concludes  his  article  by  stating  that  "unsuspected  cases 
of  status  lymphaticus  are  often  invoked  after  tonsil  operations,  which  are 
due  entirely  to  the  ether  being  administered  intermittently  and  the  sub- 
ject rapidly  coming  part  way  out  of  the  anesthesia  rather  than  to  any 
connection  of  the  tonsils  with  the  thymus." 


SPECIAL    OPERATIONS 

Short  Operations. — Precautions. — As  many  fatalities  have  been  re- 
ported from  all  anesthetics  for  short  operations,  it  is  well  to  state  the 
means  of  avoiding  them  or  reducing  them  to  the  minimum  in  the  fu- 
ture. 

First:  With  the  exception  of  emergency  cases,  all  patients  should 
be  as  well  prepared  for  a  minor  operation  as  for  a  major  one. 

Second:  Eules  regarding  diet,  cleansing  of  the  gastro-intestinal 
tract,  and  also  preliminary  medication,  if  the  psychic  element  is  in  evi- 
dence or  much  suffering  is  anticipated  after  the  operation,  must  not  be 
neglected. 

Third:  Constrictions  around  the  neck  and  waist,  such  as  a  tight 
collar  band,  corsets,  or  belts,  should  be  removed. 

Fourth :  The  head  and  trunk  should  be  in  one  straight  line  and  the 
anesthetic  given  as  speedily  as  consistent  with  safety. 

Eegardless  of  the  anesthetic  used,  all  bandages  around  the  abdomen 
or  neck  should  be  cut,  but  not  necessarily  removed.  It  is  impossible  to 
induce  a  smooth  anesthesia  with  bandages  in  place.  In  all  operations 
upon  the  head,  neck,  or  upper  air  passages  the  anesthesia  must  be  con- 
siderably lessened  before  the  bandages  are  reapplied,  otherwise  cyanosis 


338  ANESTHESIA 

may  appear  and  the  patient  will  remain  under  the  anesthetic  an  unneces- 
sarily long  time.  When  the  sitting  or  semi-sitting  position  is  used, 
chloroform  must  not  be  given. 

Nitrous  Oxid. — For  all  short  operations  nitrous  oxid,  first  through 
valves  and  then  with  to-and-fro  breathing  until  deep  anesthesia  ensues, 
is  the  best  method.  Hasbrouck,^  of  New  York  City,  who  has  given 
nitrous  oxid  for  the  extraction  of  teeth  over  100,000  times,  prefers 
nitrous  oxid  alone,  and  administers  oxygen  only  as  indicated.  From  his 
large  experience  he  declares  that  while  patients  suifer  little  nausea  or 
vomiting  from  the  combination  of  oxygen  with  nitrous  oxid,  a  still 
smaller  percentage  have  any  after-effects  with  the  nitrous  oxid  alone. 

No  one  is  justified  in  giving  nitrous  oxid  without  having  ianhs  of 
oxygen  in  place  and  available  for  immediate  use. 

Nitrous  oxid  is  the  recognized  anesthetic  for  the  extraction  of  teeth. 
It  should  also  be  used  for  dislocations,  opening  abscesses,  breaking  up 
adhesions,  examinations,  removing  or  reapplying  painful  dressings,  etc. 

For  prolonged  dental  work  the  nasal  inhaler  should  be  used  and  a 
combination  of  nitrous  oxid  and  oxygen  under  pressure  given. 

Nitrous  oxid  and  oxygen  may  be  used  for  its  analgesic  quality,  the 
patient  never  reaching  the  anesthetic  stage. 

Exceptions  to  the  above  rule  for  selecting  nitrous  oxid  or  nitrous 
oxid  and  oxygen  for  short  operations  is  where  there  is  any  great  swelling 
or  engorgement  of  the  neck.  The  administration  of  gas  in  this  condi- 
tion may  quickly  induce  dangerous  symptoms.  The  author  knows  of  one 
case  in  which  a  fatality  occurred  when  nitrous  oxid  and  oxygen  were 
given  for  the  extraction  of  a  tooth.  An  undetected  abscess  at  the  base  of 
the  tongue  burst  at  the  height  of  anesthesia  and  immediately  filled  the 
patient's  lungs  with  pus,  the  patient  dying  within  three  minutes. 

Ethyl  Chlorid. — Ethyl  chlorid  is  contraindicated  for  extraction  of 
teeth  unless  oxygen  is  used  with  it  or  nitrous  oxid  is  not  available,  not 
only  on  account  of  the  possibility  of  a  fatality,  but  also  because  of  the 
nausea  and  dizziness  that  so  often  follow  a  short  application  of  this  anes- 
thetic, the  percentage  of  cases  nauseated  being  much  greater  than  when 
nitrous  oxid  or  nitrous  oxid  and  oxygen  are  used. 

Chloroform  and  Ether. — Chloroform  is  contraindicated,  as  there  is 
a  very  great  possibility  of  a  fatality  unless  a  deep  anesthesia  is  main- 
tained.   There  is  no  contraindication  to  ether  except  for  the  after-effects. 

In  ophthalmic  cases,  in  which  quiet  is  absolutely  essential,  chloroform 
by  the  vapor  method,  and  with  oxygen,  is  preferable  to  any  other  com- 
bination. This  applies  especially  to  such  operations  as  iridectomies. 
Nitrous  oxid  with  air  or  oxygen  is  contraindicated  in  these  cases  on 
account  of  increased  congestion  of  the  blood  vessels,  as  is  also  any  closed 
method.     For  enucleations  a  preliminary  medication  is  indicated,  and 

^Personal  communication. 


ANESTHETIC  AND  TECHNIQUE  FOR  SPECIAL  OPERATIONS    339 

some  closed  method  preferably  should  be  used  to  initiate  the  anesthetic. 
The  narcosis  should  be  continued  with  some  form  of  vapor  anesthesia. 
Chloroform  should  be  avoided  if  possible  at  this  time.  It  is  unnecessary 
now,  as  formerly,  to  anesthetize  deeply  with  ether  and  depend  upon  the 
resulting  anesthesia  for  the  operation. 

Paracentesis  of  the  membrana  tympani  should  only  be  done  under 
nitrous  oxid  with  oxygen  (preferably)  or  nitrous  oxid  alone.  Ethyl 
chlorid  would  be  the  third  choice. 

The  Mastoid. — Of  all  serious  surgical  cases  the  easiest,  from  the 
anesthetic  standpoint,  is  a  mastoid  operation.  A  deep  anesthesia  is  re- 
quired only  in  the  initial  stages.  The  hammering  and  chiseling  seem 
to  have  some  anesthetic  effect,  as  the  vapors  can  be  almost  withdrawn 
and  the  reflexes  allowed  to  become  quite  active  without  the  patient  evin- 
cing any  conscious  movement.  If  nausea  follows  a  mastoid  operation, 
the  anesthetist  has  not  measured  up  to  his  opportunities. 

Generally  speaking,  the  best  procedure  for  mastoid  cases  is  to  begin 
the  anesthetic  by  the  drop  method  of  chloroform,  gradually  switching  to 
the  drop  method  of  ether  and  then  changing  to  the  oxygen-ether  vapor 
method.  This  gets  the  anesthetist  completely  out  of  the  way  and  the 
patient  comes  out  of  this  anesthetic,  as  a  rule,  without  any  nausea,  vomit- 
ing, or  shock. 

The  nitrous  oxid-ether  sequence  or  any  closed  method  is  contra- 
indicated,  as  the  bag  and  mask  are  more  or  less  in  the  surgeon's  and 
assistant's  way.  Preliminary  medication  of  morphin  or  something  simi- 
lar is  most  helpful  in  these  cases. 

The  Tipper  Respiratory  Tract. — In  all  operations  upon  this  part  of 
the  body  a  preliminary  douching  with  some  antiseptic  (in  some  in- 
stances to  clear  the  parts  of  the  blood  and  pus)  is  absolutely  essential. 

As  a  general  rule,  any  closed  method  should  be  avoided  with  this 
special  class  of  operations.  Chloroform  for  the  induction,  and  chloro- 
form and  oxygen,  or  ether  and  air,  for  the  maintenance,  is  the  best 
procedure. 

Excision  of  the  Tongue. — The  majority  of  surgeons  seem  to  prefer 
the  dorsal  position  for  excision  of  the  tongue,  with  a  sandbag  under  the 
shoulders,  or  with  the  headpiece  slightly  dropped.  In  this  position,  when 
the  head  is  well  flexed  and  the  anesthetist  supports  the  lower  jaw  with 
one  hand,  a  clear  airway  is  easily  maintained,  the  blood  and  other  secre- 
tions being  more  easily  removed  than  by  any  other  method,  and,  conse- 
quently, with  less  discomfort  to  the  patient  afterward.  Some  surgeons 
prefer  the  upright  position.  The  anesthesia  can  be  easily  maintained  by 
means  of  this  vapor  method,  with  the  tube  ending  in  the  mouth  or 
nose,  or  pharyngeal  or  intratracheal  insufflation.  Pharyngeal  anes- 
thesia (see  p.  335)  is,  as  a  rule,  all-sufficient. 

For  excision  of  the  glands  of  the  neck  or  operations  upon  the  lips 


340  ANESTHESIA 

and  cheeks  some  form  of  vapor  anesthesia  should  be  employed.  In  all 
of  these  eases  a  deep  anesthesia  is  best,  unless  facilities  for  removing 
blood  are  not  adequate  when  the  patient's  cough  reflex  is  allowed  to  re- 
main.    ' 

Cleft  Palate. — It  is  well  to  avoid  gas  as  the  initiatory  anesthetic  for 
these  operations,  anesthol  or  chloroform  being  the  best.  The  anesthesia 
can  be  maintained  by  ether  with  oxygen  or  air  and  by  the  vapor  method. 

In  intranasal  and  antrum  of  Highmore  operations  the  anesthesia 
should  be  maintained  by  the  vapor  method. 

Submucous  Operations. — While  the  majority  of  j^hysicians  do  these 
operations  in  their  offices  under  some  local  anesthetic,  lately  it  has  been 
urged  that  these  can  be  better  operated  upon  under  a  general  anesthetic. 
Closed  methods  should  be  avoided,  and  the  anesthetic  should  usually  be 
induced  with  chloroform  and  maintained  with  chloroform  and  ether  by  a 
tube  in  the  mouth.  The  patient  should  always  have  some  preliminary 
medication. 

Adenoid  and  Tonsil  Cases.- — In  adenoid  and  tonsil  cases,  to-and-fro 
breathing  of  nitrous  oxid  followed  immediately  by  ether,  and  supple- 
mented later  by  the  vapor  of  ether  passed  through  a  tube  placed  either 
in  the  mouth  or  nostrils,  is  the  best.  In  all  operations  upon  adults, 
where  the  mouth  must  be  open,  as  the  excision  of  the  tongue,  jaw,  etc., 
the  vapor  method  should  be  used,  preceded  by  the  drop  method  of  chlo- 
roform and  ether,  or  the  nitrous  oxid-ether  sequence,  according  to  the 
patient.  The  exception  to  this  rule  will  be  where  the  patient  has  some 
lung  trouble.  In  that  instance,  rectal  or  morphin  anesthesia,  or  spinal 
analgesia,  should  be  used. 

Alexander's- ^and  .Gwathmey's  technique  ^  in  adenoid  and  tonsil  opera- 
tions covers  the  ground  for  the  operations  in  the  recumbent  position. 
We  quote  voluminously  from  this  paper.  The  ideals  for  which  one 
should  strive  may  be  divided  as  follows:  1,  preparation  of  patient;  2, 
good  anesthesia ;  3,  good  technique ;  and,  4,  after-treatment. 

Preparation  of  Patient. — The  night  previous  to  the  operation  the 
patient  is  given  a  cathartic;  to  adults,  some  cathartic  pill;  to  children, 
castor  oil  or  calomeL  The  next  morning,  if  the  result  is  not  satisfac- 
tory, a  simple  enema  should  be  given,  at  least  two  hours  before  the  opera- 
tion. The  temperature  is  then  taken.  'No  food  is  allowed  for  six  hours 
before  the  time  of  operation.  If  the  operation  is  early  in  the  morning, 
no  food  whatever  should  be  given.  The  last  meal  should  consist  of  a 
plate  of  clear  soup  or  bouillon  with  two  crackers.  Cases  are  on  record 
of  children  vomiting  a  bolus  of  food  or  a  small  piece  of  undigested  meat, 
which,  getting  into  the  trachea,  caused  serious  disturbances,  even  septic 
pneumonia.     Milk  is  especially  prohibited.     From  nervousness  or  other 

^"Technique  in  Adenoid  and  Tonsil  Operations,"  N.  ¥.  Med.  J.,  March  11, 
1911. 


ANESTHETIC  AND  TECHNIQUE  FOR  SPECIAL  OPERATIONS    341 

causes  this  coagulates,  and  the  vomited  curds  are  as  much  of  a  menace 
as  particles  of  any  other  article  of  food. 

For  nervous  children  over  six  years  of  age,  chloretone,  five  grains, 
given  one  hour  before  operation,  is  valuable.  From  fifteen  years  up- 
ward, one-eighth  or  one-sixteenth  grain  of  morphin,  and  one  one-hun- 
dredth-and-fiftieth  grain  of  atropin  should  be  given,  or  ten  grains  of 
chloretone  one  hour  before  operation. 

Immediately  before  the  operation,  the  upper  air  passages  should  be 
sprayed  with  some  antiseptic  solution.  Liquid  petrolatum  with  men- 
thol is  especially  recommended,  as  it  lubricates  the  passages,  facilitating 
the  passing  of  the  catheters.  This  procedure  has  quite  a  psychic  effect, 
in  addition  to  the  physical,  that  is  most  beneficial. 

In  addition  to  the  preliminary  treatment,  mental  suggestion  is  here  of 
the  utmost  importance,  and  varies  with  the  characteristics  of  difl^erent 
patients. 

On  the  table,  the  j)atient  wears  a  loose,  warm  gown  or  robe,  thick 
woolen  socks,  and  is  covered  by  a  blanket,  over  which  is  placed  a  rubber 
sheet,  fitting  closely  around  the  neck.  Care  should  be  taken  to  prevent 
any  constriction  at  the  neck  or  waist.  The  hair  is  covered  with  a  sterile 
towel,  as  is  also  the  rubber  sheet. 

Anesthesia. — The  ideal  anesthetic  for  this  particular  operation 
must  be  safe;  deep  enough  to  abolish  all  reflexes,  including  the  cough, 
swallowing,  and  tongue  reflexes;  and  continuous,  so  that  there  will  be 
no  necessity  for  the  reapplication  of  the  anesthetic  or  for  the  delay  caused 
lay  the  removal  of  blood  from  the  operative  field.  Furthermore,  the  pa- 
tient should  come  out  of  the  anesthetic  within  fifteen  minutes,  in  a  natu- 
ral way,  without  delirium  or  nausea.  Vomiting  is  reduced  to  a  mini- 
mum if  no  blood  is  allowed  to  enter  the  stomach  during  the  operation. 

For  a  very  nervous,  child,  or  one  having  experienced  previous  fright 
from  any  cause,  the  time  of  operation  should  be  in  the  early  morning, 
say,  one  hour  before  the  usual  time  for  the  child  to  awaken,  or  during 
the  noonday  nap. 

The  patient  should  be  anesthetized  while  asleep.  This  has  been  done 
many  hundreds  of  times,  and  with  children  is  much  safer  than  any  other 
method.  To  successfully  anesthetize  a  sleeping  child,  the  mask  or  gauze 
should  never  touch  the  face.  The  anesthetic  is  begun  with  chloroform, 
a  few  drops  at  a  time,  and  gradually  increased  until  rhythmical  and 
automatic  respiration  indicates  the  commencement  of  surgical  anes- 
thesia.   A  change  to  ether  by  the  vapor  or  drop  method  is  then  made. 

On  account  of  the  undeveloped  muscles  of  children  under  six  years  of 
age,  these  patients  should  be  anesthetized  by  the  vapor  or  drop  method 
of  ether  or  chloroform.  Any  closed  method  puts  too  severe  a  strain  upon 
the  chest  walls.     The  usual  procedure  is  as  follows: 

In  all  cases  in  which  the  drop  or  vapor  method  is  used,  a  few  drops 


342  ANESTHESIA 

of  cologne  upon  the  mask,  just  before  the  anesthetic  is  started,  will  allay 
fear,  and  increase  confidence  in  the  anesthetist.  From  three  to  six  drops 
of  chloroform  are  then  given,  followed  by  as  many  of  ether,  then  alternat- 
ing, and  changing  entirely  to  ether  as  surgical  anesthesia  is  reached. 
This  procedure  gets  the  patient  under  the  anesthetic  in  from  three  to  five 
minutes,  and  without  any  struggling. 

One  should  always  bear  in  mind  that  many  of  these  little  patients 
have  the  lymphatic  temperament,  in  which  chloroform  is  absolutely 
contraindieated.  Whenever  this  is  suspected,  the  drop  method  of  ether, 
given  carefully  and  slowly  at  first,  and  increased  rapidly  as  the  stage  of 
surgical  anesthesia  approaches,  will  bridge  over  the  disagreeable  features 
which  sometimes  occur  with  this  method  of  anesthesia. 

From  six  years  of  age  upward,  decidedly  the  best  technique  is  the 
gas-ether  sequence,  followed  by  the  vapor  method.  The  ether  or  chloro- 
form is  passed  through  a  tube  attached  to  the  mouth  gag. 

If  a  patient  has  bronchitis  or  a  catarrhal  condition  of  the  upper  air 
passages,  ether  is  absolutely  contraindieated.  Warm  chloroform  and 
oxygen  is  the  safest  anesthetic  for  this  condition. 

.The  tube  on  the  suction  apparatus  in  the  mouth,  as  employed  in  a 
large  number  of  cases,  has  been  found  to  be  more  or  less  in  the  way,  and, 
to  obviate  this,  we  have  adopted  the  plan  of  placing  the  catheters  at- 
tached to  the  suction  apparatus  in  the  nares,  so  that  the  ends  are  just 
visible  when  the  tongue  is  depressed.  This  compels  the  patient  to  breathe 
through  the  mouth,  and  the  anesthesia  is  more  easily  maintained  in  this 
way  than  by  any  other  method.  (Fig.  93.)  The  patient  thus  receives 
all  the  vapor,  and  the  blood  is  not  in  the  way  of  the  operator.  Surgical 
anesthesia  is  as  easily  maintained  in  this  way  with  ether  as  with 
chloroform. 

Hewitt  uses  the  gas-ether-chloroform  sequence  for  this  operation,  as 
do  also  others  who  make  a  specialty  of  anesthetizing  for  nose  and  throat 
operations. 

With  the  bent  tube  in  the  ether  chamber  we  are  enabled  to  get  a  more 
nearly  saturated  ether  vapor  than  ever  before,  thereby  rendering  the  use 
of  the  chloroform  unnecessary  in  a  large  majority  of  cases.  This  method 
seemed  to  work  well  in  one  or  two  cases,  but  was  not  a  complete  success, 
so  we  finally  abandoned  it  and  developed  the  present  method. 

So  far,  the  nasal  tubes  have  acted  perfectly  in  taking  up  the  blood, 
and  no  trouble  is  experienced  in  keeping  a  clear  field  for  the  operator. 
A  tube  was  formerly  attached  to  the  tongue  depressor,  but  it  was  found 
that  the  tongue  depressor  had  to  be  removed  occasionally,  during  which 
time  the  patient  might  regain  the  lost  reflexes  and  thus  cause  the  sur- 
geon embarrassment.  With  the  vapor  apparatus  as  now  perfected,  we  are 
able  to  give  a  continuous  anesthesia  after  the  mouth  gag  has  been  placed 


ANESTHETIC  AND  TECHNIQUE  FOR  SPECIAL  OPERATIONS     343 


in  position,  and  the  patient  is  in  any  posture  desired  by  the  surgeon. 

If  the  operator  prefers  the  patient  in  a  dorsal  position,  it  is  unneces- 
sary to  turn  the  head  to  either  the  right  or  left,  to  stop  the  operation  for 
the  reapplication  of  the 
anesthetic  mask,  or  to  re- 
move the  blood  from  the 
oral  or  nasal  cavities. 

By  means  of  this  con- 
tinuous narcosis,  together 
Avith  the  use  of  the  blood 
suction  apparatus,  the 
time  of  operation  is  re- 
duced from  one-third  to 
one-half.  The  surgeon  is 
also  enabled  to  do  more 
thorough  work,  without 
the  feeling  of  the  neces- 
sity of  hurrying  lest  the 
patient  come  out  of  the 
anesthetic,  since  as  even  a 
plane  of  anesthesia  can 
thus  be  maintained  as  for 
any  other  surgical  pro- 
cedure. 

Deep  chloroform  nar- 
cosis, with  great  profusion 
of  hlood  in  this  position,  is 
more  or  less  dangerous. 
For  this  reason  the  gas- 
ether  sequence  to  get  the 
patient  deeply  under  the 
influence,  followed  hy 
ether  vapor  anesthesia,  is 
nearly  ideal  for  this  par- 
ticular operation. 

When  ether  is  contraindicated,  a  tube  from  the  oxygen  tank  replaces 
the  foot  pump.  Warm  oxygen  alone,  or  oxygen  with  chloroform,  may 
thus  be  given  as  indicated  (Fig.  107). 

Suction  Apparatus. — This  consists  of  a  vacuum  water  pump  (Fig. 
133),  which  is  attached  to  any  spigot  or  tap  by  an  adjustable  connec- 
tion (Fig.  133).  The  rush  of  water  through  this  brass  cylinder  creates 
a  diminished  pressure  which  is  transmitted  to  a  Wolff  bottle  by  connect- 
ing rubber  hose.     Another  rubber  hose  leads  from  the  Wolff  bottle  to 


Fig.  132. — The   Watek  Suction  Apparatus  foe 
Adenoid  and  Tonsil  Operations. 


344 


ANESTHESIA 


the  patient;  to  the  free  end  of  this  hose  are  attached  two  rubber  cathe- 
ters, which,  when  placed  in  position,  utilize  the  vacuum  and  complete 
the  apparatus. 

Good  Technique. — The  desiderata  in  the  matter  of  good  technique 
are :    1,  Good  light ;  2,  bloodless  field ;  and,  3,  maximum  speed. 

Good  Light. — After  experimenting  with  various  forms  of  reflected 
light,  we  find  direct  illumination  of  the  operative  field  to  be  the  most 


Fig.  133. — Pump  Attached  to  Spigot  With  Water  Turned  On. 


desirable.  This  is  obtained  by  using  an  electric  headlight  and  condenser, 
supplied  by  a  dry  cell  battery,  or,  better,  by  a  current  controller.  Shielded 
lights  on  instrument  and  anesthetic  tables  prevent  interference  with  the 
operator's  light. 

By  means  of  the  brilliantly  illuminated  field  so  provided,  anomalies 
of  formation  are  noted,  and  bleeding  vessels  may  be  seen  and  clamped, 
thereby  avoiding  much  tissue  laceration  and  bleeding. 

Bloodless  Field. — Our  attempts  at  reaching  this  ideal  are  still  in  the 
formative  period;  so  much  has  already  been  gained,  however,  that  we 
feel  justified  in  reporting  the  method.  Our  efl:orts  were  addressed  to, 
firstly,  the  reducing  of  the  blood  lost ;  and,  secondly,  to  the  removal  of 


ANESTHETIC  AND  TECHNIQUE  FOR  SPECIAL  OPERATIONS    345 

that  which  was  lost.  We  attempted,  as  detailed  under  anesthesia,  to  de- 
crease by  sequestration  the  amount  of  blood  volume  in  the  operative  area. 
Our  experiments  to  date  have  convinced  us  that  this  procedure,  when 
perfected,  may  be  of  positive  value.  Immediately  after  the  enucleation, 
a  pad  of  gauze,  firmly  pressed  into  the  bleeding  area,  helps  to  reduce  tlie 
hemorrhage ;  however,  the  sum  total  of  blood  lost  was  not  much  affected, 
until,  after  much  experimenting,  we  evolved  the  present  method  of  blood 
removal.  This  consists  of  a  graduated  AYolff  bottle,  suction  pump,  and 
attachments. 

Eubber  catheters,  with  several  additional  holes  made  near  their  tips, 
are  introduced  through  the  nares  as  soon  as  surgical  anesthesia  is  pres- 
ent. They  are  allowed  to  lie  alongside  of  each  other  in  the  pharynx, 
their  ends  about  an  inch  above  the  epiglottis.  The  enlarged  ends  of  the 
catheters  are  joined  by  a  Y  connection  with  the  rest  of  the  apparatus, 
the  tube  passing  over  the  patient's  head.  With  the  patient's  head  thrown 
back,  this  region  becomes  a  natural  reservoir,  which  is  thus  readily 
drained. 

As  soon  as  we  began  using  this  method,  we  noticed  a  marked  reduc- 
tion in  the  amount  of  blood  and  mucus  collected.  Previous  to  using  the 
catheters,  our  average  of  many  cases  was  four  ounces;  now  it  is  seldom 
over  two.  A  study  of  the  blood  supply  of  the  tonsillar  area  throws  no 
light  on  the  reason  for  the  diminished  hemorrhage,  yet  it  has  occurred  in 
too  many  cases  to  be  a  coincidence. 

After  complete  removal  of  adenoids  and  tonsils,  the  patient  is  turned 
on  one  side,  the  catheters  are  withdrawn,  and  the  vault  is  explored  with 
the  finger  for  shreds. 

The  vault  is  now  wiped  over  with  alcohol  on  gauze,  and  the  nares  are 
douched  with  cold  saline  solution.  This  latter  procedure  washes  out  all 
clotted  blood,  and  hastens  the  patient's  return  to  consciousness. 

Maximum  Speed. — Maximum  speed  is  obtained  by  simplicity  of 
method  in  operating.  A  skilled  anesthetist  and  an  assistant  physician 
or  nurse  are  essential.  An  occasional  swab  is  employed  to  remove  clotted 
blood  not  sucked  up  by  the  catheters.  The  adenoids  are  then  removed 
in  the  usual  way.    The  average  time  of  operation  is  eight  minutes. 

After-treatment. — The  patients  are  kept  in  bed  for  twenty-four 
hours,  and  given  liquid  food.  The  throat  is  sprayed  every  two  hours 
with  mild  liquid  antiseptics  and  a  hydrogen  peroxid  solution,  used  alter- 
nately. When  cervical  stiffness  is  present,  massage  and  hot  applications 
are  employed.     Complications  are  met  with  appropriate  remedies. 

The  Upright  Position. — Many  operators  prefer  the  upright  posi- 
tion for  adenoid  and  tonsil  operations.  French,^  of  Brooklyn,  has  de- 
vised a  chair  table,  and  has  worked  out  a  technique  that  approaches  the 
ideal  for  operations  in  this  position.  "The  method  consists  in  placing 
.      ^Trench,  Thomas  E.:     N,  Y.  Med.  J.,  June  1,  1912,  1125. 


346 


ANESTHESIA 


the  patient  upon  a  table  for  anesthetization  in  the  recumbent  position, 
and,  when  tlie  stage  of  excitement  has  passed,  in  converting  tlie  table  into 


Fig.  134a. — Dr.  French's  Chair  Table. 


a  chair  and  bringing  the  body  to  the  sitting  posture ;  or,  for  that  matter, 
placing  it  in  almost  any  position  except  one  with  the  face  downward. 
(See  Figs.  134a  to  134 j.) 


Fig.  134b. — Dr.  French's  Chair  Table. 


"Before  the   patient   is   wrapped   in   a   blaiiket,   a   stout,   four-inch 
bandage  is  made  to  encircle  the  upper  part  of  the  back,  the  ends  being 


ANESTHETIC  AND  TECHNIQUE  FOR  SPECIAL  OPERATIONS    347 

drawn  up  under  the  axillae  and  over  the  front  of  the  shoulders,  and  for 
the  moment  allowed  to  hang  in  the  recesses  on  either  side  of  the  head 


Fig.  134c. — Dr.  French's  Chair  Table. 


rest  (Fig.  134  B).  After  the  patient  has  been  wrapped  in  a  blanket, 
the  leather  straps  attached  to  the  seat  are  fastened  rather  loosely  around 
the  hips,  and  the  legs,  below  the  knees,  are  strapped  to  the  footrest 
(also  shown  in  Fig.  134  C).     When  the  patient  is  nearly  anesthetized 


Fig.  134d. — Dr.  French's  Chair  Table. 


the  anesthetist  turns  the  wheel  at  the  junction  of  the  back  of  the  chair 
with  the  seat,  and  the  body  is  thus  raised  sloAvly  forward  (Fig.  134  D)  to 


348  ANESTHESIA 

the  upright  position,  the  mechanism  being  so  constructed  that  as  the 
back  ascends  the  footrest  descends.  The  seat,  which  is  a  trifle  higher  in 
front  than  at  the  back,  is  covered  with  a  mat  of  corrugated  rubber, 
which  checks  largely,  if  not  entirely,  the  tendency  of  the  body  to  slide 
toward  the  foot  of  the  table  or  chair.  While  the  upward  movement  is 
taking  place,  the  headrest  is  adjusted  to  the  patient's  head  by  means  of 


Fig.  134e. — Dr.  French's  Chair  Table. 

the  smaller  wheel  on  the  side  of  the  back  section  (Fig.  134  E),  and  this 
is  accomplished  with  such  ease  and  accuracy  that  the  position  of  the 
head  for  the  proper  administration  of  the  anesthetic  and  the  desired  dis- 
play of  the  field  of  operation  can  be  readily  maintained.  At  the  same 
time  the  shoulder  bandage  is  adjusted  by  drawing  the  ends  around  the 
headrest,  when  they  are  caught  under,  and  tied  to  a  hook  on  the  back  of 
the  chair.  The  patient  has  now  reached  the  upright  position  and  is  ready 
for  operation.  If  the  surgeon  desires  to  operate  while  standing,  the 
chair  part  of  the  mechanism  can  be  raised  (by  means  of  the  large  wheel 


ANESTHETIC  AND  TECHNIQUE  FOR  SPECIAL  OPERATIONS    349 

in  the  frame  of  the  base)  sufficiently  to  bring  the  head  of  the  patient 
opposite  his  own  (Fig.  134  F).  If,  however,  he  desires  to  operate  while 
sitting,  the  chair  can  be  lowered,  if  necessary,  as  far  as  the  base  (Fig. 
134  G),  and  these  movements  can  be  made  with  surprising  ease,  even  if 
the  patient's  body  is  of  great  weight.  Figure  134  G  also  shows  the 
anesthptist  standing  inside  the  rear  part  of  the  frame  of  the  base,  in 


Fig.   134f. — Dh.  French's  Chair  Table. 

which  position  he  can  administer  the  anesthetic  and  control  the  mechan- 
ism of  the  chair.  If  respiratory  troubles  arise,  and  it  is  desired  to  lower 
the  patient's  head,  this  can  be  quickly  done  by  tilting  the  chair  backward 
(Fig.  134  H),  and  then  by  wheel  action  converting  the  chair  into  a  table 
top  in  the  Trendelenburg  position  (Figs.  134  I  and  134  J). 

"With  an  ordinary  chair,  or  even  with  the  special  chair  as  previously 
constructed,  it  has  been,  at  times,  very  difficult  to  place  and  keep  the 
head  of  the  patient  in  the  required  position  for  the  proper  administra- 
tion of  the  anesthetic  and  for  easy  access  to  the  field  of  operation.  With 
the  new  method,  the  inexperienced  interne  or  newly  graduated  medical 


Fig.  134g. — Dr.  French's  Chair  Table. 


Fig.  134h. — Dr.  French's  Chair  Table. 


ANESTHETIC  AND  TECIiNIQUE  FOR  SPECIAL  OPERATIONS    351 


Fig.  134r. — Dr.  Fbench's  Chair  Table. 


man  can,  under  instruction,  bring  the  patient  to,  and  maintain  him  in, 
the  upright  position,  with  perfect  ease  and  safety.  This  is  accomplished 
partly  by  means  of  wheel  devices,  the  slightest  turn  of  which  either  raises 
or  lowers  the  upper  portion  or  the  whole  of  the  body,  or  elevates  or  de- 


FiG.  134j. — Dr.  French's  Chair  TABiiE. 


352  ANESTHESIA 

presses  the  headrest,  and  that,  too,  without  further  need  of  attention 
than  is  required  in  turning  them. 

''The  secret  of  a  safe  and  an  uninterrupted  administration  of  an 
anestlietic  in  the  upright  position  is  in  keeping  the  neclv  somewhat 
stretched  and  the  head  moderately  extended  over  the  headrest." 

French  states  that  "a  sudden  change  from  the  horizontal  to  the  up- 
right position,  while  the  patient  is  under  ether  narcosis,  is  apt  to  occa- 
sion a  too  rapid  development  of  cerebral  anemia  and  a  consequent  loss 
of  cardiac  balance. 

"Experience  would  seem  to  show  that  the  danger  of  blood  flowing  into 
the  trachea  is  no  greater  during  the  routine  operations  which  we  are  wont 
to  perform  in  the  nose  and  throat  when  the  body  is  upright  than  when 
in  the  Eose  position. 

"The  blood  thus  flowing  into  the  gastro-intestinal  tract  has  never, 
in  our  experience,  made  its  presence  manifest  by  untoward  disturbances 
in  that  canal.  Our  results,  in  the  considerable  number  of  patients  upon 
whom  we  have  operated  in  the  upright  position,  have  led  us  to  the  con- 
viction that  the  fear  of  blood  flowing  into  the  air  passages  is  based  upon 
theory  and  not  upon  fact. 

"There  is  less  shock,  and  less  disturbance  in  other  ways,  to  the  pa- 
tient after  operation  because  less  ether  is  required  to  maintain  narcosis 
when  the  sitting  posture  has  been  attained.  This  is,  no  doubt,  due  to  the 
diminished  blood  pressure  in  the  vessels  of  the  head  when  the  body  is 
in  the  upright  position  and  under  the  influence  of  a  general  anesthetic. 
The  difference  between  the  flushed  face  in  the  recumbent  position  and 
its  relatively  pale  appearance  in  the  upright  position  is  at  times  very 
marked.  The  difference  in  the  quantity  of  the  anesthetic  required  is, 
we  believe,  due  to  the  difference  in  the  amount  of  blood  in  the  brain  in 
the  two  positions,  which,  in  French's  opinion,  is  another  reason  for  this 
special  technique. 

"The  abstraction  of  a  considerable  quantity  of  blood  from  an  anemic 
child  adds  to  the  cachexia,  diminishes  its  rallying  powers,  and  reduces 
the  body  resistance  in  the  event  of  the  onset  of  any  special  disorder. 
Shock  is  felt  more  by  the  child  than  the  adult,  and  although  the  child 
recovers  from  the  shock  more  rapidly  the  ultimate  recovery  will  be  re- 
tarded if  a  considerable  amount  of  blood  has  been  lost.  As  a  rule,  chil- 
dren in  a  fair  state  of  health  before  operation  sustain  the  loss  of  a  rela- 
tively large  quantity  of  blood  in  a  very  remarkable  way,  and  in  time 
recover  their  usual,  if  not  better,  health,  but  they  do  not  always  do  so 
without  concurrent  disturbances;  and  how  often  such  disturbances  are 
due  directly  or  indirectly  to  the  loss  of  blood  it  may  be  difficult  to  say." 

For  operations  upon  the  tonsils  and  adenoids  under  nitrous  oxid  and 
oxygen,  see  page  156. 

Tracheotomy. — It  is  sometimes  safer  to  perform  this  operation  under 


ANESTHETIC  AND  TECHNIQUE  FOR  SPECIAL  OPERATIONS     353 

a  local  anesthetic  on  account  of  the  congestion  produced  or  difficulty  in 
breathing  if  a  general  anesthetic  is  used.  When  there  is  no  obstruction 
in  any  part  of  the  air  passages,  there  is  no  objection  to  doing  a  trache- 
otomy under  general  anesthesia.  After  the  tracheal  tube  is  inserted, 
anest"hesia  is  easily  maintained  by  chloroform  or  ether  vapor.  If  no 
vapor  apparatus  is  convenient,  an  ordinary  mask  is  held  over  the  trachea, 
and  the  anesthetic  carefully  given.  For  thyroidectomies  careful  pre- 
liminary medication  is  essential,  and  the  anesthcJtic  should  be  instituted 
very  slowly  and  carefully.  Chloroform  and  oxygen  is  probably  the  best 
anesthetic  to  use.  Any  closed  method  is  contraindicated,  as  there  is 
always  the  possibility  of  the  thyroid  lessening  the  diameters  of  the  air 
passages  by  pressure. 

Goiter  (Angina  Lndovici,  Exophthalmos — Graves'  Disease). — If  a 
general  anesthetic  is  determined  upon,  ether  and  chloroform  with  oxygen 
by  a  tube  is  probably  the  best  method  of  administration.  Closed  methods 
should  be  avoided  with  these  cases,  as  deaths  have  been  reported  under 
nitrous  oxid  and  ethyl  chlorid.  Many  surgeons  prefer  a  local  anesthetic. 
(See  page  XIV.) 

Crile's  method  of  "stealing  upon  the  thyroid"  has  been  widely 
adopted.       He  states: 

"In  cases  of  Graves'  disease  the  mere  proposal  to  perform  an  opera- 
tion becomes  also  a  pathological  excitation;  this  excitation  may  so  much 
increase  the  disease  that  the  patient  is  even  less  able  than  before  to  bring 
herself  to  submit  to  adequate  treatment.  On  all  sides  this  disease  is 
beset  by  vicious  circles;  by  pathological  interactions.  The  ideal  plan  of 
approach,  at  least  in  my  experience,  is  to  assure  the  patient  that  hers 
is  a  curable  malady,  that  it  can  be  treated  in  a  hospital,  and  that  non- 
operative  measures  will  first  be  tried;  then  if  they  prove  inadequate  a 
simple  operation  will  be  done;  that  it  will  be  best  to  leave  this  decision 
to  the  judgment  of  her  medical  adviser,  and  that,  since  even  the  discus- 
sion of  operation  is  both  unpleasant  and  injurious,  it  would  be  best  not 
to  open  this  subject  again.  The  patient  usually  gladly  consents  to  leave 
the  whole  matter  to  the  judgment  of  the  physician,  and  the  way  is  then 
opened  for  the  most  effective  treatment  which  in  my  judgment  has  ever 
been  proposed — namely,  ligation  or  excision  on  the  new  principle  of 
anoci-association." 

The  technique  is  as  follows :  "For  about  five  days  before  the  opera- 
tion the  patient  is  treated  every  morning.  A  hypodermic  injection  of 
sterile  water  and  inhalation  of  fresh  air  with  a  little  nitrous  oxid 
through  the  same  inhaler  that  will  be  used  on  the  day  of  operation  is 
what  constitutes  the  treatment.  The  entire  treatment  lasts  five  minutes 
each  day.  The  tachycardia  and  other  nervous  symptoms  that  usually 
occur  with  each  treatment  become  less  marked  as  the  day  of  operation 
approaches.     On  the  morning  of  the  operation,  which  is  performed  in 


354  ANESTHESIA 

one  of  the  favorable  phases  of  the  numerous  cycles  of  the  disease,  the 
patient  receives  the  treatment  as  usual.  One-eighth  to  one-sixth  of  a 
grain  of  morphin  and  scopolamin  (atropin  should  be  omitted  in  these 
cases)  is  substituted  for  the  sterile  water,  and  the  nitrous  oxid  is  carried 
to  the  stage  of  surgical  anesthesia.  The  patient  falls  asleep  in  her  bed 
without  realizing  that  the  first  step  of  an  operation  has  already  begun. 
The  patient  is  then  transported  anesthetized  to  the  operating  room, 
where  the  operative  field  is  prepared.  The  anticipation  of  the  operation 
and  excitement  usually  attendant  upon  the  induction  of  anesthesia, 
sometimes  producing  fatal  shock,  are  by  this  method  eliminated. 

"Up  to  this  point  the  patient's  brain,  hence  the  remainder  of  the 
body,  is  in  a  negative  state,  and  this  is  half  of  the  innovation  of  the 
specialized  operation;  the  other  half  is  this:  any  injury  of  any  sensitive 
part  of  the  body,  though  the  patient  is  under  inhalation  anesthesia,  ex- 
cites the  brain,  and  hence,  through  the  brain,  all  of  the  motor  mechan- 
ism, especially  the  thyroid.  Inhalation  anesthesia  is  but  a  thin  veneer, 
and,  although  the  patient  is  unconscious,  the  afferent  impulses  set  up  by 
the  operation  reach  the  brain  apparently  as  readily  as  if  no  anesthetic 
was  given. 

"This  is  the  source  of  the  hyperthyroidism,  so  called,  that  constitutes 
the  greatest  danger  of  the  operation.  Operation  under  inhalation  anes- 
thesia on  any  sensitive  part  of  the  body  produces  precisely  the  same  ex- 
acerbation of  the  disease  (hyperthyroidism)  as  operations  upon  the  thy- 
roid gland  itself.  How  may  this  be  avoided  ?  It  may  be  wholly  avoided 
by  the  use  of  complete  local  anesthesia  in  addition  to  general  anesthesia, 
by  the  use  of  novocain  throughout  the  entire  operation,  just  as  com- 
pletely as  if  the  patient  had  received  no  general  anesthesia." 

"By  this  technique,"  Crile  states,  "the  scope  of  the  operation  is 
greatly  increased  and  the  gland  can  be  safely  removed  from  any  patient 
whose  condition  will  endure  the  metabolic  influence  of  the  sudden  with- 
drawal of  so  much  active  gland  tissue." 

With  operations  upon  the  hrain,  it  is  better  to  use  chloroform  and 
oxygen.  Nitrous  oxid  and  oxygen  are  contraindicated,  as  they  raise  ar- 
terial tension  with  unnecessary  bleeding.  For  the  same  reason  ether 
should  be  avoided  as  a  preliminary,  as  any  struggling  will  immediately 
induce  congestion  with  increased  bleeding.  In  an  emergency  case,  or  if 
the  patient  is  unconscious,  preliminary  medication  should  be  avoided. 

Amputations. — For  amputations,  dislocations,  setting  fractures,  and 
similar  operations,  preliminary  medication  is  essential,  and  a  fairly  deep 
anesthesia  should  be  used.  Gas  and  oxygen  by  some  closed  method  is 
preferable  for  work  of  this  character. 

Operations  Upon  Fingers  and  Toes. — Operations  upon  fingers  and 
toes  require  a  deep  anesthesia  in  order  to  avoid  reflex  movements,  on 
account  of  the  unusually  large  nerve  supply  in  these  parts. 


ANESTHETIC  AND  TECHNIQUE  FOR  SPECIAL  OPERATIONS     355 

Circumcision. — For  circumcision  of  a  child  the  hcst  plan  is  to  start 
with  one  or  two  drops  of  the  essence  of  bitter  orange  peel  and  supplement 
this  with  chloroform  drop  by  drop  until  the  second  stage  is  reached, 
when  a  switch  to  ether  by  the  drop  method  is  instituted.  A  change  to 
the  closed  method  may  then  be  advantageously  made.  The  anesthesia 
should  be  considerably  lessened  before  the  final  dressings  are  applied. 

Rectal  Cases. — All  rectal  cases  should  have  full  physiological  doses 
of  morphin  with  some  other  drug.  The  anesthesia  can  be  induced  and 
maintained  with  nitrous  oxid  and  oxygen  or  ether  by  the  closed  method. 
Chloroform  should  be  avoided  in  these  cases. 

Obstetric  Cases. — In  obstetrical  practice,  on  account  of  the  enlarge- 
ment of  the  heart  at  that  period,  and  the  patient  always  welcoming  the 
anesthetic,  chloroform  with  oxygen  is  preferred,  and  is  unattended  with 
the  immediate  risk  that  might  be  inseparable  from  chloroform  at  an- 
other time.  An  additional  reason  for  chloroform  being  safe  at  this  time 
is  the  continuous  dilatation  of  the  sphincters  of  the  uterus  and  vagina, 
compelling  the  patient  to  take  deep  breaths,  and  thereby  get  rid  of  the 
anesthetic  almost  as  soon  as  administered.  A  deep  anesthesia  is  not 
indicated  at  any  time,  both  on  account  of  the  child  and  the  mother.  The 
anesthesia  should  be  maintained  between  the  second  and  third  stages  if 
possible.  The  reported  fatalities  from  chloroform  in  this  connection  are 
exceedingly  rare,  and  are  usually  due  to  gross  carelessness,  ignorance,  or 
attempting  to  maintain  too  deep  an  anesthesia.  If  ether  is  used  it  can 
easily  be  deodorized  by  the  vapor  method.  Kitrous  oxid  and  oxygen 
given  to  the  stage  of  analgesia  is  becoming  more  and  more  popular. 

Anesthesia  should  be  avoided  during  the  menstrual  period,  as  there  is 
a  greater  possibility  of  hysterical  or  maniacal  excitement  afterward.  If, 
however,  an  operation  is  imperative,  a  warm  oxygenated  chloroform 
vapor  is  indicated. 

Curettage. — For  curettage  or  similar  operations,  nitrous  oxid  and 
oxygen,  or  warm  chloroform  vapor  with  oxygen  or  air,  if  the  type  of 
patient  permits,  is  best. 

Genito-urinary  Operations. — In  genito-urinary  operations,  where 
deep  anesthesia  is  always  required,  the  nitrous  oxid-ether  sequence  is  in- 
dicated. 

Laparotomy. — In  laparotomies,  where  absolute  relaxation  is  required, 
the  nitrous  oxid-ether  sequence,  to-  be  followed  by  chloroform  when  the 
patient  is  in  the  Trendelenburg  position,  is  the  combination  preferred  by 
such  men  as  Hewitt  ^  and  Boyle. ^  Boyle's  routine  procedure  is  to  change 
to  chloroform  or  the  chloroform-ether  mixture  after  fifteen  or  twenty 
minutes. 

Chloroform  is  administered  with  less  danger  when  the  patient  is  in 

*  Hewitt :      ' '  Ansesthetics. ' ' 

^  Boyle :     ' '  Practical  Anaesthetics, ' '  142. 


356  ANESTHESIA 

the  Trendelenburg  position,  on  account  of  the  large  amount  of  blood  in 
the  brain  at  that  timfe.  Eelaxation  of  the  abdominal  musch^s  is  assisted 
by  placing  a  sandbag  under  the  knees  and  slightly  raising  tlie  shoulders. 
Gastro-enterostomy  and  Similar  Operations. — In  addition  to  the 
usual  preliminary  preparation,  Crile's  method  is  as  follows : 

"Starved  and  Anemic  Patients. — A  preliminary  transfusion  of 
blood  brings  back  the  vitality  of  patients  exsanguinated  by  hemorrhages 
and  makes  them  good  risks;  thus  the  surgeon  may  reclaim  the  bad  risks 
in  hemorrhage  from  ulcer  of  the  stomach  or  duodenum. 

"In  starvation  cases  the  risk  cannot  be  so  successfully  reclaimed, 
though  the  patient  may  be  much  improved  by  transfusion.  The  risk  in 
these  cases  is  not  shock  and  depression,  but  a  broken  metabolism  ex- 
pressing itself  as  acidosis. 

"Since  employing  transfusion  I  have  had  the  opportunity  of  seeing 
more  clearly  the  dangers  of  acidosis,  for  I  have  operated  on  cases  all  but 
moribund,  and  have  seen  them  pass  through  the  operation  unchanged, 
and  have  seen  metabolic  death  follow.  Heretofore  such  cases  would  not 
have  been  operated,  and  if  operated  would  not  have  survived  long  enough 
for  study.  There  is  a  stage  of  acidosis  rather  easily  recognizable  which 
proves  fatal  as  a  metabolic  process  in  spite  of  complete  control  of  the 
blood  volume,  and  measurably  of  the  blood  pressure.  This  does  not  in 
the  least  apply  to  acute  or  chronic  hemorrhage.  Here  transfusion  gives 
an  absolute  control." 

Crile  states,  further,  that  "the  combination  of  nitrous  oxid,  general 
anesthesia,  and  novocain,  local  anesthesia  and  quinin,  and  urea  hydro- 
chlorid  as  a  post-operative  anesthesia  combined  with  ample  incision  and 
gentle  handling  establishes  anoci-asso elation — or  shockless  operation." 

Other  surgeons  get  excellent  results  by  starting  a  hypodermoclysis 
as  soon  as  the  patient  is  in  surgical  anesthesia  and  continuing  this 
throughout  the  operation.  As  much  as  two  quarts  of  normal  saline  can 
be  taken  by  a  patient  in  this  way  with  splendid  results.  With  the  vapor 
method  of  ether  anesthesia,  the  patient's  pulse  can  be  easily  maintained 
at  normal,  provided  the  surgeon  is  gentle  in  his  manipulation. 

Peritonitis  or  Intestinal  Obstruction. — If  morphin  has  been  used  to 
quiet  pain  the  anesthetist  should  be  informed  of  this  fact.  Otherwise 
too  deep  an  anesthesia  may  be  instituted  at  the  commencement  of  the 
operation.  Surgeons  here  should  not  insist  upon  absolute  relaxation,  as 
in  many  cases  it  is  almost  impossible  to  maintain  this  condition.  If 
regurgitation  of  fecal  matter  is  present,  the  stomach  should  be  well 
washed  out  before  the  induction  of  the  anesthetic  and  the  stomach  tube 
left  in  place  during  the  operation.  The  open  method  of  administration 
should  be  used,  initiated  preferably  with  chloroform  and  continued  with 
ether.  If  vomiting  occurs,  the  anesthetist  must  immediately  insert  a 
mouth  gag  (but  must  not  pull  the  tongue  forward)  and  with  his  finger 


ANESTHETIC  AND  TECHNIQUE  FOR  SPECIAL  OPERATIONS    357 

or  a  sponge  on  a  sponge  holder  keep  the  throat  absolutely  clear.     Death 
by  suifocation  is  always  imminent  in  these  cases. 

CONCLUSIONS 

With  these  general  indications  as  a  guide,  it  can  readily  be  seen  how- 
impossible  it  is  to  say  that  some  one  anesthetic  should  be  used  at  a  cer- 
tain age,  or  for  a  given  disease,  or  for  some  specific  operation.  The  con- 
ditions blend  in  such  a  way  that  the  anesthetic  must  be  selected  for  each 
case;  the  safety  of  the  patient,  and  the  successful  termination  of  the 
operation,  being  the  results  sought.  If  the  surgeon  is  so  situated  that 
he  must  work  without  a  trained  assistant  and  without  the  refinements  of 
anesthesia  customary  in  the  larger  cities,  ether  should  be  the  anesthetic 
of  choice.  Finally,  when  thus  handicapped,  the  surgeon  should  always 
remember  that  it  is  possible  with  morphin  and  whiskey,  plus  a  very 
small  amount  of  general  anesthetic,  to  complete  successfully  nearly  any 
operation.  Fatalities  have  unquestionably  occurred  from  the  use  of 
some  one  anesthetic  or  method.  No  hospital  or  clinic  can  be  considered 
to  rank  among  the  first  when  a  routine  procedure  is  countenanced.  When 
for  any  reason,  after  careful  choice  and  deliberation,  the  anesthetic  is 
taken  badly  a  change  should  be  made  immediately, 

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ANESTHETIC  AND  TECHNIQUE  FOR  SPECIAL  OPERATIONS    359 

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CHAPTER   IX 

TEEATMENT   BEFOEE,   DURING,   AND   AFTER   ANESTHESIA 

Duties  of  the  Anesthetist  in  Addition  to  Giving  Anesthetic. 

The  Anesthetist's  Kit:  Anesthetist's  Motto;  Mouth  Gag;  Con- 
tents of  Kit ;  Emergency  Treatment  to  Insure  Breathing. 

The  Management  of  Ordinary  Cases  :  Preliminary  Treatment ; 
Treatment  During  Anesthesia;  After-Treatment. 

Management  of  Difficult  or  Unusual  Cases:  Respiratory; 
Muscular;  Nervous;  Idiosyncratic;  Shock;  Post-Anesthetic  Toxemia. 


DUTIES  OF  THE  ANESTHETIST   IN  ADDITION  TO  GIVING  THE 

ANESTHETIC 

The  anesthetist  who  thinks  his  duties  comprise  getting  the  patient 
under,  maintaining  narcosis  until  the  surgeon  gives  the  signal  to  Jet  up, 


Fig.  135. — Supporting  Jaw  to  Maintain  Free  Airway  with  Two  Fingers  on  the 

Carotid  Artery. 


and  seeing  to  it  that  the  patient  is  safely  removed  from  the  operating 
table  to  the  bed  is  doomed  to  failure.  Much  more  than  this  devolves 
upon  him.     He  must  be  assured  that  the  proper  preliminary  hygienic, 

361 


362  ANESTHESIA 

psychic,  and  medicinal  preparation  is  attended  to;  he  must  find  out 
whether  the  breathing  is  oral  or  nasal,  and  direct  his  anesthetic  vapor  ac- 
cordingly; he  must  keep  a  clear  airway  either  by  manipulating  the  lower 
jaw  or  by  a  suction  pump  or  sponging;  he  must  maintain  an  even  nar- 
cosis; he  must  keep  the  mouth  gag  (if  used)  in  position;  he  must  pro- 
tect the  patient  from  too  much  pressure  upon  the  throat  and  chest  either 
from  artery  forceps,  or  from  an  assistant  or  anyone  leaning  too  heavily 
upon  the  chest;  he  must  assist  the  surgeon  in  any  way  that  may  be  de- 
sirable, according  to  the  exigencies  of  the  case.  He  must  be  equipped 
for  the  management  of  all  manner  of  emergencies  which  may  concern 
his  part  of  the  surgical  procedure  or  the  after-treatment  of  the  case. 

In  order  to  meet  the  exigencies,  whatever  their  nature,  as  they  arise, 
the  following  equipment  will  be  found  invaluable: 


THE    ANESTHETIST'S    KIT 

Anesthetist's  Motto. — The  difficulty  with  all  inhalation  methods  of 
administration,  as  before  mentioned,  is  respiratory.  While  the  motto  of 
the  anesthetist  should  be  Anticipation,  yet  there  sometimes  occur  cases 
in  which  asphyxial  symptoms  take  such  a  course  that  interference  is 
necessary  in  order  to  retain  a  clear  air  passage. 

Mouth  Gag. — The  skilled  anesthetist  seldom  uses  a  mouth  gag  and 
tongue  forceps.  In  thousands  of  cases  it  should  not  be  necessary.  (This 
does  not  apply  to  cases  in  which  the  mouth  is  to  be  operated  upon.) 
Nevertheless,  the  anesthetist  should  always  be  prepared  to  use  both. 

Contents  of  Kit. — The  following  is  a  list  of  the  apparatus  that  should 
be  convenient  wh^enever  an  anesthetic  is  given,  regardless  of  the  method : 

(1)  A  wooddii  gag  or  screw  with  which  to  open  the  mouth. 

(2)  Mouth  gag,  so  patterned  that  the  blades  will  fall  one  behind  the 
other  when  closed,  this  being  the  easiest  to  place  between  the  teeth. 

(3)  Tongue  forceps.  The  best  tongue  forceps  have  a  small  projec- 
tion to  clasp  the  tongue  directly  in  the  middle.  If  this  is  placed  in  the 
median  line,  there  will  be  little  or  no  bleeding,  as  there  are  very  few 
blood  vessels  and  nerves  in  this  part  of  the  tongue.  The  tongue  is  really 
composed  of  two  parts  joined  in  the  median  line.  The  tongue  forceps 
with  two  projections  will  invariably  cause  a  flow  of  blood. 

(4)  A  tracheotomy  set.  This  should  be  in  a  case,  every  part  steri- 
lized, and  ready  for  use.  It  should  not  be  open  unless  an  emergency 
calls  for  its  use. 

(5)  A  curved  needle  threaded  with  silk,  sterilized,  and  wrapped  up. 

(6)  A  hypodermic  syringe. 

Emergency  Treatment  to  Insure  Breathing. — Whenever  the  anesthet- 
ist anticipates  trouble  of  any  kind,  he  should  examine  the  mouth  of  the 


TREATMENT  BEFORE,  DURING,  AND  AFTER  ANESTHESIA     3G3 

patient,  and,  if  tliis  is  not  clone  before  the  administration,  it  requires 
but  a  second  to  open  the  lips  and  determine  immediately  which  side  of 
the  mouth  will  be  the  best  in  which  to  place  the  wooden  wedge  or 
screw.  Before  placing  the  wedge  or  gag  in  the  mouth,  however,  the 
anesthetist  should  exhaust  every  plan  to  have  the  patient  breathe  natu- 
rally. If  unsuccessful  in  this,  while  every  second  counts  in  an  emer- 
gency, it  is  unnecessary  to  destroy  or  injure  the  patient's  teeth.  After 
the  mouth  has  been  opened  sufficiently  with  the  wooden  screw,  place  the 
mouth  gag  in  position,  insert  the  tongue  forceps  in  the  median  line, 
one-half  to  one  inch  from  the  tip  of  the  tongue,  and  pull  the  tongue 
forward.  If  an  airway  is  thus  secured,  and  the  patient  recommences 
breathing,  it  is  always  best  to  then  remove  the  tongue  forceps  and  gag. 
Nevertheless  it  must  be  borne  in  mind  that,  if  such  a  procedure  has  be- 
come necessary  once,  it  is  likely  to  recur  at  any  time.  Very  little  trac- 
tion is  necessary  to  pull  the  tongue  forward.  In  addition  to  moving  the 
jaw  and  head  in  different  directions,  one  of  the  best  means  of  overcom- 
ing asphyxial  symptoms  is  by  placing  a  tube  from  the  oxygen  tank  in 
the  nose  or  the  mouth.  If  a  stream  of  oxygen  has  to  be  kept  up  in  this 
way  during  the  remainder  of  the  operation,  the  patient  will  be  no  worse 
for  it. 

Again,  the  anesthetist  must  bear  in  mind  that,  if  in  the  midst  of  an 
operation  asphyxial  symptoms  continue  to  assert  themselves,  it  is  always 
possible  to  considerably  diminish  the  amount  of  pulmonary  anesthetic 
by  administering  a  hypodermic  of  morphin. 

For  excision  of  the  tongue,  or  any  operation  in  which  it  is  necessary 
to  hold  it  forward  for  any  length  of  time,  a  thread  would  be  less  in  the 
way  than  the  tongue  forceps.  The  needle  should  be  inserted  in  about 
the  same  place  as  the  tongue  forceps,  the  thread  pulled  through  and  tied 
in  a  convenient  loop,  and  the  needle  cut  off.  The  thread  may  then  be 
caught  with  an  artery  forceps. 

It  is  the  purpose  of  this  chapter  to  give,  in  condensed  form,  certain 
practical  suggestions  concerning  the  management  of  surgical  cases,  from 
the  anesthetist's  point  of  view.  It  is  now  well  known  that  the  success 
of  the  anesthesia  as  regards  the  ultimate  Recovery  of  the  patient  is  largely 
dependent  upon  the  preliminary  preparation,  the  treatment  during  the 
course  of  the  narcosis,  and  the  care  after  the  anesthesia  is  discontinued. 

In  order  to  render  this  part  of  the  present  volume  as  available  as  pos- 
sible for  practical  purposes,  the  subject  is  divided  into:  (1)  The  man- 
agement of  ordinary  cases  before,  during,  and  after  anesthesia;  (2)  the 
management  of  difficult  and  exceptional  cases  before,  during,  and  after 
anesthesia. 


364  ANESTHESIA 


THE  MANAGEMENT  OF  ORDINARY  CASES 

Under  this  category  come  the  ordinary  run  of  surgical  cases — pa- 
tients who  need,  perhaps,  a  certain  amount  of  suggestive  therapy  along 
with  the  requisite  medicinal  treatment,  regardless  of  the  anesthetic 
agent  to  be  employed. 

Preliminary  Treatment 

The  preliminary  preparation  of  a  patient  about  to  be  anesthetized 
may  be :  ( 1 )  Hygienic ;  ( 2 )  psychic ;  ( 3 )  medical.  Some  patients  re- 
quire one  or  the  other;  others  require  all  the  preliminary  adjuvants 
that  may  be  brought  into  requisition. 

Hygienic. — Grooming  of  Patient. — The  patient  should  be  as  thor- 
oughly prepared  (as  far  as  his  or  her  condition  permits)  as  if  for  an  ath- 
letic event.  A  warm  bath  with  thorough  cleansing  of  the  skin  and  a 
shampoo  for  the  hair,  followed  by  an  alcohol  rub,  should  precede  all 
other  treatment.  Eemoval  of  hair  over  and  adjoining  site  of  operation 
with  scissors  and  razor  should  be  done  the  night  previous  to  a  morning 
operation,  or  in  the  morning  for  an  afternoon  operation.  "One  of  the 
most  essential  points  in  preparing  the  patient  for  operation  is  to  make 
sure  that  the  preceding  night  is  a  restful  one.  If  the  patient  is  in 
pain,  or  is  particularly  nervous,  a  hypnotic  should  always  be  admin- 
istered." ^ 

The  Mouth  and  Kose. — If  possible,  a  dentist  should  cleanse  the 
teeth  thoroughly,  removing  loose  and  hopelessly  decayed  teeth,  and  then 
giving  the  patient  a  suitable  antiseptic  mouth  wash  to  be  used  every  four 
or  five  hours  until  time  for  the  operation.  This  wash  should  be  used 
to  cleanse  the  nasal  passages  as  well. 

"The  disinfection  of  the  mouth  is  a  matter  of  so  much  importance 
in  the  prevention  of  pneumonia  from  aspiration  during  anesthesia  that 
it  should  never  be  neglected.^'  Hydrogen  dioxid,  one  part  to  three  of 
water,  or  potassium  permanganate  in  a  weak  solution,  may  be  used  for 
this  purpose. 

The  Bladder. — "Patients  should  eithjer  empty  the  bladder  or  be 
catheterized  immediately  before  the  operation. 

"If  urine  is  scanty,  bicarbonate  of  potash  or  citrate  of  potash 
in  small  quantities,  not  more  than  30  or  30  grains  within  twenty- 
four  hours,  added  to  pure  water  should  be  given  freely  to  flush  the 
kidneys. 

"Should  a  more  active  diuretic  be  desired,  small  doses  of  sweet  spirit 
of  niter  may  be  added  to  the  draft,  since  this  simple  remedy  acts  as 

^ ' '  American  Practice  of  Surgery, ' '  4,  132. 


TREATMENT  BEFORE,  DURING,  AND  AFTER  ANESTHESIA     365 

an  efficient  diuretic,  in  many  cases  overcoming  any  tendency  to  spasm 
of  the  renal  vessels  and  flooding  these  organs  witli  blood. "^ 

Intestinal  Tract. — No  athlete  is  ever  given  a  purge  on  the  night 
immediately  preceding  a  contest,  and  the  time  should  be  past  when  a 
patient  is  thus  debilitated  before  entering  the  operating  room. 

All  are  agreed  on  the  advisability  of  emptying  the  intestinal  tract, 
the  method  and  time  of  doing  this  varying  with  different  hospitals  and 
surgeons. 

"Two  days  before  the  operation  the  patient  is  given  one  or  two  table- 
spoonfuls  of  castor  oil  or  a  dessertspoonful  of  natural  Carlsbad  salts 
in  a  glass  of  warm  water,  or  at  noon  on  the  day  before  the  operation 
a  purgative  should  be  given,  followed  in  eight  or  nine  hours  by  an  enema, 
the  amount  of  purging  being  increased  or  diminished  according  to  the 
patient's  strength. 

"In  intestinal  obstruction,  with  frequent  vomiting  or  regurgitation, 
a  careful  insertion  of  the  stomach  tube,  which  may  be  left  in  place,  is 
necessary  before  commencing  the  anesthesia. 

"The  bowels  should  not  act  more  than  twice  in  the  twenty-four  hours 
previous  to  the  operation.  Many  surgeons  dispense  entirely  with  purga- 
tion, as  the  worst  condition  of  all  is  when  the  patient  is  suffering  from 
an  artificial  diarrhea  at  the  time  of  operation.  The  number  of  bacteria 
increases  as  the  intestinal  contents  become  more  liquid,  and  diminishes 
with  the  abatement  of  the  diarrhea. 

*'^The  intestinal  tract  should  be  cleansed  and  practically  emptied  be- 
fore the  time  of  operation.  Two  ounces  of  castor  oil  are  administered 
12  to  16  hours  before  operation,  ■  and  the  large  bowel  is  emptied  by  a 
soapsuds  enema  on  the  morning  of  the  operation.  The  cleansing  of  the 
entire  intestinal  tract,  together  with  the  withholding  of  nourishment, 
renders  the  canal  practically  sterile  in  its  upper  portions,  facilitates 
intra-abdominal  manipulation,  and  lessens  the  possibility  of  gaseous  dis- 
tention after  the  operation.  The  administration  of  sterilized  foods  is 
also  a  good  procedure."  ^ 

Diet. — "While  advantageous  to  have  the  stomach  empty,  it  is  not 
essential  to  starve  the  patient  for  twelve  or  eighteen  hours.  Easily  di- 
gested gruels  of  barley  or  rice  can  be  given  in  small  quantities  up  to 
within  two  or  three  hours  of  the  operation  with  distinct  advantage. 
Starchy  gruels  permit  the  liver  to  store  up  glycogen  and  thereby  place 
it  in  a  favorable  position  for  maintaining  its  function.  Animal  broths 
throw  an  undue  strain  upon  the  kidneys  in  the  elimination  of  extrac- 
tives. Hunter  believes  that  the  absence  of  glycogen  from  the  liver,  by 
diminishing  the  combustion  processes  in  that  organ,  diminishes  the  anti- 
toxic power  of  the  liver  cells,  so  that  the  starved  individual  is  more 

'Keen's  "Surgery,"  5,  1008. 
^Am.   J.  Surg.,  4,   131. 


366  ANESTHESIA 

easily  affected  by  poisons  than  the  glycogen-rich  person.  So,  too,  an 
absence  of  carbohydrate  material  results  in  extensive  changes  in  fat 
metabolism,  which  results  in  an  increased  formation  of  acid,  and  so 
tends  to  the  development  of  acidosis."  ^ 

"The  patient  should  be  kept  in  bed  and  given  liquid  diet  for  eighteen 
hours  prior  to  the  operation.  Water  is  freely  given  by  mouth  up  to 
within  three  hours  of  the  time  of  operation.  The  practice  of  withhold- 
ing water  involves  unnecessary  hardship  and  discomfort,  while  its  free 
administration  aids  materially  in  the  subsequent  elimination  of  ether, 
and  is  undoubtedly  a  factor  in  preventing  the  possibility  of  shock.  When 
inadvisable  to  give  water  by  mouth,  one-half  pint  of  normal  saline  may 
be  administered  per  rectum  two  hours  before  the  patient  goes  on  the 
table."  2 

Psychic. — Some  patients,  as  we  have  stated,  require  one  or  all  forms 
of  preliminary  preparation  in  order  to  insure  a  smooth,  safe,  and  alto- 
gether satisfactory  anesthesia.  The  expert  anesthetist  must  be  able  to 
judge  of  the  particular  requirements  of  the  individual  case.  Over 
seventy  per  cent  of  cases,  according  to  conservative  estimates,  require 
both  mental  and  medical  treatment  in  order  to  insure  the  best  results. 

Children  and  nervous  and  irritable  adults  require  psychic  preparation 
for  the  coming  ordeal,  and  the  anesthetist  who  ignores  this  factor  runs 
the  risk  of  having  to  deal  with  more  or  less  serious  difficulties  during 
some  portion  of  the  time  when  the  patient  is  under  his  care.  In  this  con- 
nection the  Chapter  on  Hypnotism  will  be  found  helpful. 

Idiots  and  insane  persons,  as  a  rule,  require  only  medical  prepara- 
tion. In  many  cases,  however,  in  which  the  mental  defect  is  of  a  mild 
degree  of  severity,  the  patient  is  susceptible  to  the  reassuring  influence 
of  a  calm  and  forceful  personality.  Those  who  have  had  occasion  to  wit- 
ness operations  in  homes  or  hospitals  for  defectives  or  the  insane  have 
observed  this.  The  senior  author  (J.  T.  G.)  recalls  the  case  of  a  feeble- 
minded boy  who,  when  about  to  be  operated  upon  for  the  removal  of 
adenoids  and  tonsils,  flew  into  an  uncontrollable  rage  at  the  sight  of  one 
anesthetist,  who  made  no  pretense  of  giving  the  patient  the  benefit  of 
suggestive  therapy,  whereas  another  anesthetist,  availing  himself  of  this 
aid,  experienced  no  difficulty  in  getting  the  child  to  take  the  anesthetic 
quietly. 

Patients  already  in  a  state  of  coma  require  no  preliminary  treat- 
ment. 

Necessity  for  Preliminary  Mental  Preparation. — "There  can 
be  little  doubt  that  the  mental  condition  of  the  patient  does  not  receive 
enough  attention  from  the  average  anesthetizer.  It  is  remarkable  that 
patients,  whose  thoughts  are  made  to  run  in  pleasant  channels  as  the  an- 

»  Keen 's  ' '  Surgery, ' '  5,  1000. 

'"American  Practice  of  Surgery,"  4,  131. 


TREATMENT  BEFORE,  DURING,  AND  AFTER  ANESTHESIA     367 

esthetic  is  first  given,  usually  take  the  drug  more  quietly  than  those  who 
inhale  it  in  a  condition  of  mental  distress.  This  is  particularly  true  of 
nervous  women  and  children.  When  the  fears  of  a  patient  who  is  con- 
scious are  developed  into  the  terrors  of  semiconsciousness,  in  which  the 
patient  imagines  the  most  frightful  accidents  are  taking  place,  it  can  be 
readily  understood  that  profound  nervous  shock  is  produced."  ^ 

"Where  but  little  is  required  to  turn  the  scales  toward  the  side  of 
death,  unquestionably  fear  may  sometimes  lead  to  fatal  results  through 
psychical  shock,  through  the  lack  of  cooperation  of  the  patient  in  declin- 
ing proper  nourishment,  through  loss  of  sleep,  and  finally  through  im- 
paired resistance,  which  results  from  the  combination  of  these  factors. 
Such  extreme  dread  as  is  referred  to  here  should  be  carefully  considered, 
so  that  every  effort  may  be  made  to  soothe  the  fears  of  the  sufferer,  as 
the  successful  outcome  of  an  operation  sometimes  materially  depends  on 
the  tranquilized  state  of  the  patient's  mind.  It  is  often  not  the  most 
formidable  and  dangerous  operations  which  thus  terrify  patients,  and  it 
is  not  always  the  hysterical  or  simple-minded  who  are  the  victims  of  this 
dread.  Psychical  shock,  although  rarely  fatal  of  itself,  may  readily 
prove  a  determining  lethal  factor  in  a  patient  with  unsound  organs,  who 
is  ttlso  subjected  to  the  physical  shock  and  loss  of  blood  of  an  operation."  ^ 

Crile  states  that :  "Although  there  is  not  convincing  proof,  still  there 
is  strong  evidence  that  the  effect  of  the  stimulus  of  fear  upon  the  body 
withoat  physical  activity  is  more  injurious  than  the  effect  of  fear  with 
physical  activity.  It  is  well  known  that  the  soldier  lying  under  fire 
waiting  in  vain  for  orders  to  charge  suffers  more  than  the  soldier  that 
flings  himself  into  the  fray ;  that  a  wild  animal  in  an  open  chase  against 
capture  suffers  less  than  when  cowering  in  captivity." 

If  this  is  true,  exactly  the  same  state  exists  when  a  patient  lies  in 
bed  awaiting  an  operation.  Crile  goes  even  further,  and  states :  "That 
the  brain  is  definitely  influenced,  even  damaged,  by  fear  has  been  proved 
by  the  following  experiments: 

"Eabbits  were  frightened  but  not  injured,  and  not  chased,  by  a  dog. 
After  various  periods  of  time  the  animals  were  killed  and  their  brain 
cells  compared  with  the  normal.  Widespread  changes  were  seen.  The 
principal  gross  phenomena  expressed  by  the  rabbit  were  rapid  heart, 
accelerated  respiration,  prostration,  tremors,  and  a  rise  in  temperature. 

"The  dog  showed  similar  phenomena,  excepting,  instead  of  muscular 
relaxation,  as  in  the  rabbit,  it  showed  aggressive  muscular  action.  Both 
the  dog  and  the  rabbit  were  exhausted  and,  although  the  dog  exerted 
himself  actively  and  the  rabbit  remained  physically  passive,  the  rahbit 
was  much  more  exhausted  than  the  dog. 

"Other  observations  were  made  upon  the  brains  of  foxes  chased  for 

*  Keen's  "Surgery,"  5,  p.  12. 
'Am.  J.  Surg.,  4,  120. 


368  ANESTHESIA 

various  distances  by  members  of  a  hunt  club,  then  finally  overtaken  by 
the  hounds  and  killed.  The  brain  cells  of  these  foxes  as  compared  with 
those  of  a  normal  fox  showed  extensive  physical  changes/' 

Illustrations  Showing  Necessity  for  Mental  Treatment. — 
There  is  recorded  the  history  of  a  patient  in  whom  the  psychic  element 
predominated  to  such  an  extent  that  the  patient  suddenly  expired  dur- 
ing the  shaving  of  the  groin,  preparatory  to  an  operation  for  hernia.^ 

There  is  a  record  of  another  patient  whose  dread  of  the  anesthetic 
was  such  that  the  narcotiser  dropped  water  upon  the  mask  for  a  few  min- 
utes with  the  idea  of  assuaging  his  anxiety  and  distress  of  mind,  but 
even  this  procedure  did  not  prevail,  and  the  patient  died  before  a  single 
drop  of  chloroform  touched  the  mask.^ 

A  patient  at  Bellevue  Hospital,  in  N"ew  York  City,  cut  his  throat  in 
anticipation  of  an  operation  which  was  to  be  performed  upon  him  the 
following  day. 

A  patient  (in  private  practice),  who  had  been  given  only  a  few 
breaths  of  nitrous  oxid,  jumped  from  the  table,  fled  from  the  room,  and 
was  never  afterward  located,  so  far  as  operation  was  concerned,  by  the 
surgeon.^ 

We  see  the  other  extreme  in  obstetric  practice.  The  patient  always 
welcomes  the  chloroform,  as  she  is  in  such  a  state  of  mind  that  she  is 
willing  to  do  anything  to  relieve  her  suffering.  The  vast  majority  of 
surgical  cases  come  between  these  two  extremes. 

Mental  Depression. — It  is  interesting  to  note  that  the  majority  of 
fatal  cases  reported,  in  which  the  psychic  element  predominated  to  such 
an  extent  that  a  fatality  resulted,  were  men,  and  these  are  the  patients 
who  have  this  mental  depression.  Not  only  so,  but  they  are  men  in  ro- 
bust health,  requiring  possibly  but  a  slight  operation. 

In  the  light  of  these  statistics,  it  is  wrong  to  place  an  alcoholic  or 
an  athlete  upon  the  table  without  endeavoring  to  eliminate  this  psychic 
element. 

Diagnostic  Evidences  of  Fear. — In  spite  of  the  fact  that  most 
patients  claim  not  to  be  fearful  of  the  ordeal  through  which  they  are 
to  pass,  and  possibly  present  no  outward  manifestation  of  fear,  the  anes- 
thetist, listening  to  the  heart  of  the  patient  just  before  the  administra- 
tion, discovers  that  things  are  not  what  they  appear  to  be  on  the  surface. 
In  a  great  many  instances  the  palpitation  of  the  heart  is  alarming,  and 
seems  to  be  absolutely  out  of  the  control  of  the  patient.  In  a  great  many 
others  the  heart  is  beating  faster  and  with  more  force  than  normal. 
This  state  of  affairs  means  that,  when  the  anesthetic  is  finally  adminis- 
tered, the  patient  is  in  an  attitude  to  resist  the  effects  of  the  anesthetic. 

^Sir  James  Y.  Simpson's  work,  2,  144. 

^Kappeler:      "  Anajsthetics, "    118. 

^  This  case  was  reported  to  the  senior  author  by  the  surgeon. 


TREATMENT  BEFORE,  DURING,  AND  AFTER  ANESTHESIA     369 

On  the  other  hand,  even  though  the  patient  may  say  that  she  is  afraid 
(men  never  admit  it),  if  this  patient  has  had  the  proper  preliminary 
medication,  the  heart  will  be  found  normal.  In  other  words,  the  nerv- 
ous mechanism  has  been  taken  out  of  the  patient's  control  temporarily; 
not  only  so,  but  the  mind  is  now  in  a  condition  where  a  few  suggestions 
in  the  proper  spirit  and  manner  are  readily  grasped  by  the  patient.  When 
the  patient,  thus  doubly  prepared,  has  the  anesthetic  administered,  the 
chances  are  all  in  favor  of  a  sleep  approaching  that  of  nature.  "The 
transition  from  partial  sleep  to  complete  anesthesia  is  not  so  sudden  as 
from  complete  wakefulness,  and  is  more  easily  accomplished."  (Crile.) 

Influence  of  Omission  of  All  Preliminary  Medication  in  Pos- 
sible Subsequent  Operations. — When  this  preliminary  medication  is 
omitted,  even  if  everything  goes  on,  to  all  appearances,  smoothly,  the 
patient's  condition  of  mind  as  he  approaches  the  operating  table  may 
come  back  to  him  at  some  future  time  when  a  second  operation  is  needed, 
and  so  act  upon  his  nerves  as  to  make  him  defer  the  operation  until, 
possibly,  too  late  for  anything  but  palliative  surgery. 

Importance  of  Preliminary  Medication. — Not  only  is  a  patient 
in  a  proper  frame  of  mind  to  receive  suggestions  when  preliminary  medi- 
cation is  used,  but  the  whole  nervous  system  is  obtunded,  especially  the 
olfactory  nerve  and  the  vomiting  center.  The  patient,  therefore,  takes 
more  kindly  to  the  anesthetic,  passing  quietly  and  quickly  into  full  sur- 
gical anesthesia.  If,  during  the  operation,  it  is  possible  to  lighten  the 
anesthesia  without  disturbing  the  surgeon,  the  patient  can  be  held  be- 
tween a  light  and  deep  narcosis  without  once  disturbing  the  dangerous 
vomiting  center.  The  patient  comes  out,  as  a  usual  thing,  without  either 
conscious  or  unconscious  vomiting.  The  kidneys  and  lungs  have  also 
been  saved  unnecessary  irritation  by  thus  reducing  the  amount  of  pul- 
monary anesthetic  one-third  to  one-half. 

Even  when  this  element  of  fear  is  seemingly  entirely  absent,  the  pa- 
tient, disregarding  preliminary  treatment  of  all  kinds,  incurs  a  certain 
definite  and  needless  risk,  often  out  of  all  proportion  to  the  operation 
to  be  performed.  A  gentle  laxative,  rest  in  bed  at  the  place  of  opera- 
tion, and  a  small  physiological  dose  of  morphin  or  some  other  sedative 
should  be  insisted  upon  for  even  slight  operations. 

Two  illustrative  cases  from  the  writer's  and  one  from  a  noted  sur- 
geon's practice  in  ISTew  York  City  will  suffice. 

(1)  Adenoid  and  tonsil  case  of  a  young  girl  twenty-two  years  of 
age.  She  refused  to  stay  in  a  private  sanitarium  over  night,  and  conse- 
quently did  not  have  any  morphin  preliminarily.  Patient  walked  in 
from  the  street,  and,  while  the  surgeon  and  myself  retired  to  another 
room,  disrobed  and  laid  herself  upon  the  table,  and  was  draped  by  the 
nurse  for  operation.  Heart  sounds  normal  and  no  outward,  appearance 
of  nervousness.     Induction  of  anesthesia  uneventful.     About  two  min- 


370  ANESTHESIA 

utes  after  beginning  the  operation  patient  stopped  breathing,  and  after 
the  usual  procedure  was  revived  and  the  operation  completed.  Patient 
was  compelled  to  stay  in  hospital  for  two  days  on  account  of  laxity  of 
the  sphincter  ani,  and  the  surgeon  was  put  to  his  wits'"  end  to  explain 
the  relation  of  this  condition  and  subsequent  diarrhea  to  the  adenoid  and 
tonsil  operation. 

(3)  Patient,  male,  sixty-five  years  of  age.  Carcinomatous  gland 
of  neck.  Patient  walked  into  hospital  on  the  morning  of  the  operation, 
and  had  no  preliminary  medication  before  coming  to  the  operating  room. 
Heart  slightly  hypertrophied  and  sometimes  failed  to  compensate.  After 
operation  had  progressed  about  fifteen  minutes,  respiration  ceased  for 
no  apparent  reason  except  lack  of  preliminary  treatment  of  all  kinds.  A 
quick  slap  on  chest  wall  over  precordial  region  failed  to  start  the  respira- 
tory pump.  The  head  of  the  table  was  quickly  lowered;  sphincter  ani 
stretched,  traction  on  tongue  and  artificial  respiration  with  massage  of 
precordial  region  were  immediately  instituted.  All  of  these  factors  acting 
together  resulted  finally  in  the  patient's  respiratory  center  reasserting 
itself,  and  the  operation  was  successfully  completed. 

(3)  Patient,  male,  age  thirty-five;  vigorous  health,  slight  operation 
under  cocain.  No  preliminary  medication  of  any  kind  was  attempted 
beyond  cleansing  the  immediate  field  of  operation.  A  few  drops  of  co- 
cain were  injected  into  the  urethra,  when  the  patient  immediately 
stopped  breathing,  and  all  efforts  at  resuscitation  failed. 

The  above  fatal  case  and  the  two  nearly  fatal  cases  illustrate  most 
forcibly  the  imperative  necessity  of  safeguarding  patients  by  preliminary 
medication  in  so-called  minor  operations. 

In  order  to  completely  eliminate  the  element  of  fear,  Crile  has  elabo- 
rated a  method  which  he  calls  anoci-association.  This  consists  of  block- 
ing off  the  nerve  supply  to  the  field  of  operation  (in  external  operations) 
by  the  local  or  intraneural  infiltration  of  novocain.  The  brain  is  thus 
completely  isolated  from  operative  influence,  and,  according  to  Crile,  "is 
not  more  affected  than  if  the  operation  were  performed  on  clothing." 

This  is  of  importance  aside  from  the  comfort  of  the  patient,  because, 
as  Crile  has  shown,  the  element  of  fear  has  a  definite  effect  on  the  cells 
of  the  brain.  These  changes,  to  whatever  due,  are  always  proportional  to 
the  extent  of  the  loss  of  vital  force. 

Medical.— The  medical  treatment  consists  of: 

(1)  The  treatment  necessary  to  prepare  the  patient  for  the  opera- 
tion, which  is  in  part  included  under  hygienic  treatment. 

(2)  The  narcotics  and  hypnotics  preliminarily  given  as  a  desirable 
part  of  the  anesthetic. 

There  is  a  complete  unanimity  among  surgeons  as  to  the  preliminary 
use  of  morphin  in  local,  spinal,  intravenous,  and  rectal  anesthesia.  (See 
remarks  in  each  of  these  chapters.)     On  the  other  hand,  there  is  a  wide 


TREATMENT  BEFORE,  DURING,  AND  AFTER  ANESTHESIA    371 

diversity  of  opinion  as  to  prescribing  morphin  and  other  narcotics  before 
pulmonary  anesthetics,  most  surgeons  believing  thoroughly  in  their  use, 
while  others  never  employ  them  before  an  operation,  but  inconsistently 
prescribe  some  of  them  immediately  afterward.  As  all  pulmonary  anes- 
thetics are  improved  by  use  of  these  drugs  more  than  are  the  four  spe- 
cial classes  of  anesthesia  mentioned  above,  there  should  be  a  greater 
unanimity  of  opinion  concerning  their  value  than  exists  at  present. 

EuLES  Governing  Preliminary  Medical  Preparation. — Prelimi- 
nary medication  consists  usually  of  morphin,  hyoscin,  chloretone,  bro- 
mids,  and  whiskey,  either  alone  or  in  combination.  The  following  rules 
will  assist  in  determining  whether  or  not  preliminary  medication,  and  es- 
pecially morphin,  should  be  used.^ 

(1)  Whenever  morphin  (or  other  narcotic)  is  to  be  given  at  all,  it 
should  always  be  given  before,  instead  of  after,  the  operation,  in  order  to 
obtain  the  benefits  of  it  in  the  induction  and  maintenance  of  anesthesia. 

(2)  After  taking  it,  the  patient  must  be  kept  in  bed  absolutely 
quiet,  and  at  the  proper  time  carried  to  the  operating  room. 

(3)  All  athletes,  alcoholics,  neurotic  and  plethoric  patients  should 
have  preliminary  medication  in  order  to  take  away,  as  far  as  possible, 
the  physical  control  which  might  enable  them,  when  the  second  stage  of 
narcosis  is  reached,  to  take  a  deep  breath,  hold  it,  and  thus  force  upon 
the  heart  all  the  anesthetic  vapor  in  the  lungs,  creating  an  overdose. 

(4)  In  the  extremes  of  life,  the  very  young,  the  very  old,  under 
seven  and  over  seventy,  if  morphin  is  given  at  all,  it  should  be  with  very 
great  caution. 

(5)  Whenever  morphin  is  given  a  lighter  narcosis  should  be  main- 
tained than  when  this  drug  is  not  employed. 

(6)  Care  must  be  taken  in  administering  the  usual  doses  of  mor- 
phin when  chloroform  is  the  terminal  anesthetic.  It  is  best  to  use  some 
other  drug,  as  both  morphin  and  chloroform  have  a  depressing  effect  on 
the  respiratory  centers.  Atropin  is  the  best  drug  to  employ  as  a  pre- 
liminary to  chloroform  (or  any  combintion  of  drugs  with  chloroform), 
rendering  inhibito-respiratory  reflexes  less  liable  to  occur.  If  used  alone, 
atropin,  1/100  to  1/150  of  a  grain,  30  minutes  to  1  hour  before  the 
operation,  is  the  proper  dose.  One-eighth  of  a  grain  of  morphin  with 
1/150  grain  of  atropin  is  a  good  combination  when  chloroform  is  used 
alone. 

Preliminary  narcotic  medication  increases  the  confidence  of  nervous 
patients,  lessens  the  amount  of  anesthetic  required,  prevents  the  exces- 
sive accumulation  of  mucus  in  the  throat,  reduces  the  liability  to  shock, 
and  eases  the  immediate  post-operative  pain,  while  often  giving  to  the 
patient  a  happier  exit  from  the  influence  of  the  anesthetic."  ^ 

1  Collins,  C.  U.:  J.  Am.  Med.  Assn.,  Mar.  26,  1911. 
»^m.  J.  Surg.,  4,   132. 


372  ANESTHESIA 

"Through  countless  experiments  it  has  been  found  that  narcoses  are 
possible  with  far  smaller  amounts  if  preceded  a  few  hours  before  by  a 
hypnotic,  even  though  these  hypnotics  act  on  entirely  different  organs."  ^ 

Time  for  Giving  the  Pkeliminaky  Medication. — Whenever  medi- 
cation is  used,  it  should  be  given  for  its  full  physiological  effect  to  be 
apparent  Just  before  the  time  scheduled  for  the  operation.  It  is  just  as 
important  not  to  give  the  preliminary  medication  too  long  as  too  short 
a  time  before  the  operation. 

For  morphin  or  any  of  its  combinations,  at  least  30  minutes  should 
be  allowed.  The  physiological  effect  of  morphin  and  atropin  is  indicated 
by  dryness  of  the  mouth  and  slight  slowing  of  the  heart  and  respiration. 

Doses  of  Preliminary  Medicaments. — When  chloretone  is  used 
alone,  it  is  best  to  start  at  least  1  hour  or  an  hour  and  a  half  ahead 
of  time.  Probably  the  best  way  to  give  this  drug  is  5  grains  with  % 
glass  of  water  every  15  minutes  until  15  grains  have  been  taken.  The 
last  dose  is  to  be  given  at  least  30  minutes  before  the  operation.  When 
chloretone  and  morphin  are  used  in  combination,  only  small  doses  of 
both  drugs  are  necessary,  in  order  to  have  the  desired  effect.  Ten  grains 
of  chloretone  with  i/^  glass  of  water,  1  hour  before  the  time,  and  i/g  to 
1/6  grain  of  morphin  30  minutes  before,  is  usually  sufficient. 

Some  experimental  hiboratories  report  that  y^  grain  of  morphin  with 
15  grains  of  chloretone  would  be  absolutely  safe  for  an  athlete  or  an  alco- 
holic. 

The  average  dose  is  1/8  to  1/6  grain  morphin  with  1/150  grain  atro- 
pin, for  women;  and  1/6  to  14  grain  morphin  with  1/100  grain  atropin 
for  men.  One-eighth  to  14  grain  of  morphin,  with  1/100  grain  sco- 
polamin  1^/2  hours  before  the  operation  has  been  used  by  some  surgeons 
with  very  great  success. 

Collins'  ^  perfected  technique  is  probably  the  best  ever  published,  and 
for  this  reason  is  given  in  full.  His  "final  choice  resulted  only  after 
using  hyoscin-morphin-cactin  combination  in  70  cases  and  morphin  and 
atropin  in  a  few  cases.  He  first  used  chloroform,  but  in  the  majority  of 
his  cases  ether  was  the  anesthetic  used.  Lately  he  has  been  using  nitrous 
oxid,  and  finds  this  acts  equally  well.  This  preliminary  medication  is 
given  to  all  patients  over  seven  years  old. 

In  exophthalmic  goiter  cases,  on  account  of  the  nervous  element,  it 
is  given  the  night  before  and  repeated  one  and  a  half  hours  before  the 
operation. 

All  relatives  and  friends  are  excluded  from  the  room,  and  every 
necessary  manipulation  and  handling  of  the  patient  is  now  completed. 

The  hypodermic  is  administered  1^2  hours  before  the  operation,  and 
consists  of  a  solution  containing  scopolamin,  1/100  grain,  and  morphin, 

^  Meyer  and  Gottlieb :      ' '  Experimentelle  Pharmakologie. ' ' 
^ioc  cit.,  15. 


TREATMENT  BEFORE,  DURING,  AND  AFTER  ANESTHESIA     373 

1/6  grain.  The  room  is  now  darkened  and  quiet  maintained.  In  about 
30  minutes  the  patient  becomes  drowsy  and  in  a  tranquil  condition  of 
mind. 

Twenty  minutes  before  the  operation  a  layer  of  gauze  or  cotton  is 
placed  over  the  eyes,  and  the  patient  is  now  carried  and  placed  upon  the 
operating  table. 

The  anesthetic  is  administered  while  the  final  cleansing  of  the  opera- 
tive field  is  concluded. 

After  the  operation  the  patient  usually  sleeps  from  two  to  five  hours 
before  becoming  completely  awake.  The  smarting  pain  of  a  recent  opera- 
tion is  thus  entirely  eliminated. 

In  over  1,000  cases  there  were  no  deaths  and  only  1  case  presented 
unpleasant  symptoms,  and  there  was  practically  no  post-operative  vomit- 
ing (about  1  in  10). 

Indications  and  Contraindications  or  Preliminary  Medica- 
tion.— The  contraindications  of  morphin  are  the  extremes  of  life ;  acute 
or  subacute  nephritis;  a  state  of  coma;  where,  for  any  reason,  the  re- 
flexes are  not  to  be  abolished;  in  those  extremely  rare  cases  in  which 
morphin  is  taken  with  distress,  with  accompanying  disagreeable  after- 
effects, and  especially  in  cases  of  idiosyncrasy ;  also  very  weak  and  feeble 
patients,  and  those  with  any  respiratory  affection. 

If  for  any  reason  morphin  in  any  of  its  various  combinations  is 
contraindicated,  an  ounce  of  whiskey  and  7  ounces  of  salme  solution  per 
rectum,  i/o  hour  before  the  operation,  usually  has  the  desired  effect  of 
quieting  the  patient. 

When  ether  is  contraindicated  and  chloroform  or  ethyl  chlorid  is  the 
anesthetic  of  choice,  atropin  is  especially  indicated  as  the  preliminary 
medicament  to  be  used.  It  maintains  the  respiration,  and  with  ethyl 
chlorid  prevents  profuse  salivation  with  consequent  nausea  and  vom- 
iting. 

The  experimental  and  clinical  experiences  of  Herrenschmidt  and 
Beauvy  ^  have  made  them  come  to  the  following  conclusion : 

"That  adrenal  extracts  should  be  administered  to  chloroformed  sub- 
jects, whether  the  suprarenal  capsule  shows  evidence  of  weakness  or 
whether  it  gives  evidence  of  struggle  and  consequent  reaction.  The  ef- 
fect of  prolonged  chloroform  administration  on  the  medullary  portion 
of  the  adrenal  is  diminution  and  even  disappearance  of  both  chromaffin 
and  adrenalin. 

"Delbet  has  administered  adrenalin  to  more  than  1,000  chloroformed 
patients.  The  results  have  been  splendid.  He  believes  that  adrenalin 
unquestionably  regularizes  the  narcosis  and  diminishes  (in  most  cases 
eliminates)  post-operative  shock." 

*  P,  Delbet,  A.  Herrenschmidt,  and  A.  Beauvy :  Bevue  de  chirurgie,  Apr.  10, 
1912. 


374  ANESTHESIA 

Treatment  During  Anesthesia 

The  object  of  treatment  during  anesthesia  is  the  maintenance  of  the 
patient's  vitality  on  as  nearly  normal  a  plane  as  possible. 

The  anesthetist  should  at  all  times  anticipate  the  needs  of  the  sur- 
geon, and  also  give  necessary  directions  for  any  treatment  the  patient's 
condition  demands  during  the  operation,  for  instance,  during  a  lapa- 
rotomy, if  a  Trendelenburg  posture  is  called  for  and  a  light  anesthesia 
is  being  maintained  at  the  time,  the  anesthesia  should  be  immediately 
deepened,  otherwise  the  muscles  will  stiffen  up  with  the  changed  posi- 
tion and  cause  trouble. 

Again,  if  there  is  shock  from  handling  important  vessels  and  nerves 
or  inflamed  tissues  or  breaking  up  an  adhesion,  the  anesthetic  must  be 
lessened  and  the  oxygen  increased,  and  a  rectal  saline  or  hypodermo- 
clysis  given,  thus  keeping  the  pulse  and  respiration  as  nearly  normal  as 
possible. 

Hydrant  Water  or  Saline  Enema  to  Relieve  Thirst,  Prevent  Nausea, 
and  Assist  Kidneys. — Furthermore,  to  mitigate  the  thirst  which  may 
arise  from  the  morphin,  to  give  strength  and  volume  to  the  pulse  and 
also  to  assist  the  kidneys  and  prevent  the  formation  of  gas  in  the  intes- 
tine, two  pints  of  normal  saline  solution,  105°  to  115°  F.,  per  rectum 
materially  assists  in  this  direction,  and  brings  the  patient  out  in  a  far 
better  condition  than  when  this  has  not  been  included.  This  should  be 
given  as  a  routine  measure,  and  for  the  special  purposes  here  mentioned, 
while  the  patient  is  still  in  full  surgical  anesthesia,  a  slight  Trendelen- 
burg position  assisting  greatly  in  the  retention  of  the  fluid. 

If  the  saline  enema  is  quickly  absorbed  or  has  been  given  continu- 
ously during  the  operation,  it  may  be  discontinued  10  to  15  minutes  be- 
fore the  conclusion.  Instead  of  the  normal  saline,  ordinary  hydrant 
water  may  be  used  with  advantage,  according  to  Trout.^ 

He  2  compared  over  400  alternate  cases.  Actual  experiments  proved 
that  tap  water  could  be  continued  over  a  longer  period  with  less  rectal 
irritation  than  with  any  saline  solution.  He  cites  the  fact  that  "thera- 
peutists sometimes  obtain  wonderful  results  in  the  treatment  of  acute 
and  chronic  nephritis  by  substituting  a  salt-free  diet."  He  also  refers 
to  deaths  that  "showed  experimentally  that  they  were  due  to  the  sodium 
chlorid  and  not  to  the  amount  of  water  or  to  hemolysis."  Eeference  is 
also  made  to  experimenters  who  have  "actually  produced  not  only  an 
acute,  but  a  chronic,  nephritis  in  rabbits  by  the  continual  administration 
of  this  drug."  He  refers  to  Vincent,  who  "was  able  to  control  to  a  large 
extent  a  number  of  cases  of  hysteria  by  employing  a  salt-free  diet  with- 

*  On  the  abuse  of  normal  salt  solution,  see  G.  H.  Evans:  J.  Am.  Med.  Assn., 
Dec.  30,  1911,   2126. 

2  Trout:     "Proctoclysis,"  J.  Am.  Med.  Assn.,  May  4,   1912,  1352. 


TREATMENT  BEFORE,  DURING,  AND  AFTER  ANESTHESIA     375 

out  their  knowledge,  and  accentuated  the  symptoms  by  a  corresponding 
increase  in  salt." 

Trout  mentions  specifically  one  of  his  own  cases,  an  interval  appen- 
dix, in  which  "there  followed  a  transient  alhumijiuria  which  remained 
for  two  days."  Water  was  then  substituted  for  the  salt  solution  per 
rectum,  and  at  the  end  of  twenty-four  hours  the  albumin  had  disap- 
peared. At  the  end  of  the  next  twenty-four  hours,  salt  solution  was 
again  used  and  albumin  appeared  within  the  next  twenty-four  hours. 
Salt  solution  was  then  discontinued  and  water  started,  and  the  patient 
did  not  show  any  more  albumin  up  to  the  time  of  his  discharge  from 
the  hospital.    In  this  case  there  was  never  any  edema. 

"When  a  poison  is  introduced  into  the  system  it  unites  to  form  new 
compounds  with  the  cell  protoplasm,  and  this  molecular  union  must  be 
broken  up  before  the  poison  can  be  eliminated.  Salt  solution  has  no  spe- 
cific action  in  either  bacterial  or  vegetable  poisoning. 

"If  absorption  is  a  process  of  osmosis  it  is  certainly  reasonable  to  pre- 
sume that  a  solution  which  is  not  isotonic  with  blood  will  be  more  readily 
absorbed  from  the  rectum,  and  our  series  of  cases  tends  to  confirm  this 
view." 

"Conclusions. —  (1)  All  patients  show  less  rectal  irritation  from 
proctoclysis  if  given  a  soapsuds  enema  before  the  operation. 

"(2)  The  patients  given  water  by  rectum  absorbed  nearly  400  c.  c. 
more  to  the  24  hours  than  did  the  patients  given  salt  solution,  the  aver- 
age for  the  water  series  being  2,444  c.  c.  per  24  hours  and  the  average  for 
the  salt  series  being  2,041  c.  c.  per  24  hours. 

"(3)  The  patients  given  salt  solution  by  rectum  required  nearly 
twice  as  much  water  by  mouth  to  relieve  thirst,  or,  to  give  exact  figures, 
in  the  water  cases  only  332  c.  c.  were  taken  in  the  first  24  hours;  in  the 
salt  cases  696  were  required  in  the  first  24  hours. 

"(4)      The  amount  of  urine  was  practically  the  same  in  both  cases. 

"(5)  In  17  cases  the  patients  complained  of  tasting  salt  without 
having  any  idea  that  normal  salt  solution  was  being  given  by  rectum. 
None  of  the  water  series  made  any  such  complaint. 

"(6)  In  drainage  cases  more  fluid  may  be  taken  by  rectum  than  in 
those  laparotomies  closed  without  drainage. 

"(7)  Proctoclysis  should  be  employed  more  frequently  than  it  has 
been  in  the  past  and  in  all  classes  of  cases  in  which  it  is  possible.  Care 
should  be  exercised  to  prevent  "water  logging"  of  the  entire  system,  and 
this  applies  to  both  salt  and  water. 

"(8)  In  peritonitis  cases  with  drainage  it  is  possible  to  have  the  pa- 
tients take  four  or  five  times  as  much  fluid  by  rectum  as  in  the  cases  on 
which  this  paper  is  based." 

LaAvson  ^  corroborated  Trout's  findings.    "Theoretically,  at  least,"  he 

'Lawson,  George  B. :     J.  Am.  Med.  Assn.,  Apr.  18,  1908,  1267. 


376  ANESTHESIA 

says,  "it  seems  better  in  the  toxemias  to  use  plain  water  in  place  of 
normal  saline  so  that  the  osmotic  pressure  would  increase  the  absorption ; 
also  by  increasing  the  fluids  of  the  body  without  increasing  the  sodium 
chlorid  one  better  facilitates  urinary  secretion." 

Olive  Oil  to  Restore  the  Opsonic  Index. — The  administration  of  five 
ounces  of  warm  olive  oil  is  strongly  recommended  by  Ferguson.^  He 
states  that  "anesthesia  by  ether  or  chloroform  lowers  the  opsonic  index, 
that  is  to  say,  reduces  the  patient's  power  to  resist  an  infection  which 
was  existing  at  the  time  of  the  operation  or  which  may  be  a  post-opera- 
tive acquirement;  second,  the  bacteria  are  not  materially  affected  either 
in  respect  to  number  or  activity;  third,  this  impaired  resistance  is 
brought  about  through  the  medium  of  both  phagocytes  and  serum." 

Ferguson  cites  a  number  of  experiments  to  prove  this  theory,  upon 
both  animals  and  human  beings :  "In  the  human  experiments  5  ounces 
(150  c.  c.)  of  warm  olive  oil  were  passed  slowly  into  the  rectum  through 
a  tube  immediately  after  the  patient  had  returned  from  the  operating 
room.  This  was  followed  after  three  to  six  hours  by  a  restoration  of 
phagocytic  power,  while,  on  the  contrary,  the  injection  of  the  same 
amount  of  physiologic  salt  solution  had  no  appreciable  effect  in  shorten- 
ing the  period  of  phagocytic  depression." 

It  is  suggested  that  a  certain  amount  of  the  oil  is  absorbed  and  en- 
ters the  blood  stream;  and,  furthermore,  "in  all  probability  a  certain 
amount  of  ether  is  present  in  the  intestinal  tract  which  may  be  held  by 
the  oil,  and  thus  prevented  from  becoming  reabsorbed." 

Where  long  exposure  of  intestines  is  unavoidable,  as  in  gastro-en- 
terostomy  and  similar  operations,  hypodermoclysis  should  be  begun  as 
soon  as  the  patient  is  in  surgical  anesthesia,  thus  anticipating  and  in  a 
great  measure  preventing  surgical  shock. 

When  sudden  hemorrhage  occurs  rectal  saline,  Avith  the  patient  in  a 
slight  Trendelenburg  position,  will  more  quickly  restore  the  volume  of 
blood  lost,  and  in  this  way  reestablish  circulatory  equilibrium,  than  any 
other  procedure.  This,  of  course,  is  in  addition  to  whatever  measures 
the  surgeon  may  institute  for  the  control  of  hemorrhage. 

As  a  further  preventive  of  post-operative  shock,  filling  the  abdominal 
cavity  with  oxygen  at  the  close  of  the  operation  is  a  useful  procedure. 

Aeration  of  Lungs. — As  the  operation  is  drawing  to  a  close,  if  the 
anesthetic  has  been  other  than  nitrous  oxid,  a  system  of  aeration  of  the 
lungs  should  be  initiated  as  follows : 

Place  any  mask  with  rubber  bag  over  the  face  of  a  patient  and  com- 
mence pumping  in  warm  air,  the  bag  to  be  kept  slightly  distended  or 
overdistended  for  two   or  three  minutes  and  then   emptied,   and  this 

*  Ferguson,  Eobert  H. :  "  The  Opsonic  Index  in  Eelation  to  Surgical  An- 
esthesia."     E.  E.  Squibb  &  Sons. 


TREATMENT  BEFORE,  DURING,  AND  AFTER  ANESTHESIA     377 

process  is  repeated  (unless  the  patient  is  entirely  conscious)  until  he  is 
ready  to  be  removed  from  the  operating  table. 

Removal  of  Patient. — The  patient  should  be  moved  with  as  little 
jolting  as  possible^  and  should  be  well  covered  over  with  hot  blankets 
while  on  the  stretcher,  special  care  being  taken  to  protect  the  head  as 
well  as  the  feet. 

Technique  of  Removal  to  the  Bed. — Unless  straps  are  under  the 


Fig.  136. — Prepaking  to  Lift  Fatiknt.     Head  of  patient  to  foot  of  bed. 

patient  or  there  is  an  abundance  of  help,  instead  of  lifting  the  patient 
directly  over  the  stretcher  into  the  bed,  place  the  head  of  the  patient  at 
.the  foot  of  the  bed,  the  stretcher  and  bed  thus  forming  a  right  angle, 
with  anesthetist  and  nurse  standing  within  the  angle  thus  formed.  In 
this  position  a  very  heavy  patient  can  be  easily  lifted  by  one,  or,  at  most, 
two,  people  and  placed  in  bed  without  Jarring  or  jolting  and  without 
straining  the  backs  of  those  lifting.  The  patient  should  always  be  lifted 
as  high  as  the  head,  in  order  that  the  principal  weight  of  the  body  be 
carried  in  a  vertical  position.  The  strain  upon  the  muscles  of  the  back 
is  thus  materially  lessened. 

If  a  sedative  is  indicated  after  the  operation,  it  is  best  to  use  some 
other  drug  than  morphin,  if  this  has  been  used  as  a  preliminary,  as  a 
repetition  of  morphin  may  induce  nausea.     If,  however,  it  is  repeated. 


378 


ANESTHESIA 


the  atropin  should  be  omitted,  as  the  dryness  of  the  throat  caused  by 
this  drug  is  usually  a  source  of  very  great  discomfort  to  the  patient. 
The  whiskey  and  saline  enema  is  one  of  the  best  medicaments  to  use 
after  an  ojoeration.  Chloretone,  in  5-grain  doses,  and  hyoscin,  either 
alone  or  combined  with  morphin,  is  also  good. 

Einally,  with  proper  preliminary  medication,  the  anesthetic  may  be 
discontinued  much  earlier.     Patients  iisually  continue  to  sleep  or  doze 


Fig.   137. — Carrying  Patient  Head  High.     This  patient  weighed  over  two  hundred 
pounds  and  was  easily  lifted. 

from  the  morphin  given  for  from  I/2  to  1  hour  after  the  effects  of  the  pul- 
monary anesthetic  have  worn  off.  The  acute  pain  of  the  operation  is 
thus  minimized  and  the  necessity  for  any  further  medication  is  not  so 
great. 

Aftek-tkeatment 


If  the  anesthetic  has  been  properly  administered,  all  reflexes  should 
be  present  as  the  patient  is  being  placed  in  bed. 

Two  pillows  should  be  immediately  placed  under  the  head  and  shoul- 
ders of  the  patient,  unless  indications  of  shock  are  evident.  A  towel 
should  be  placed  over  the  eyes  to  keep  out  the  light,  and  the  room  dark- 
ened but  well  ventilated,  the  patient  being  protected  from  draughts  by 


a  screen. 


TREATMENT  BEFORE,  DURING,  AND  AFTER  ANESTHESIA     379 

The  saline  or  water  enema  should  be  repeated  every  few  hours,  unless 
olive  oil  has  been  given. 

Permit  no  loud  talking  or  moving  around,  thus  allowing  the  patient 
to  sleep  partly  from  the  preliminary  medication  and  partly  from  the 
nerve  exhaustion  usually  accompanying  any  surgical  operation,  until  he 
awakens  from  this  twilight  slumber  in  a  quiet  and  natural  manner. 

Water. — As  soon  as  he  is  awake,  free  administration  of  either  cold 
or  hot  water  will  make  the  patient  comfortable.  If  nausea  is  present, 
and  vomiting  ensues,  the  stomach  is  washed  out  and  the  nausea  will 
subside  much  more  quickly  than  if  the  water  had  not  been  taken.  This 
should  be  "further  supplemented  by  small  quantities  of  salt  solution,  200 
or  300  c.  c,  per  rectum  every  4  hours.  The  free  administration  of  water 
not  only  hastens  the  elimination  of  ether,  but  also  supplies  fluid  for 
active  kidney  work  and  militates  against  the  occurrence  of  shock.  After 
36  to  48  hours,  a  liquid  diet  may  be  begun,  and  buttermilk,  fresh  milk, 
or  lager  beer,  albumin  water  flavored  with  fruit  juice  or  sherry,  or  tea  or 
coffee,  may  be  acceptable."  ^ 

For  post-anesthetic  vomiting  it  is  a  routine  custom  among  many 
British  surgeons  to  give  tincture  of  iodin,  %  minim  (i^  minim  of 
U.  S.  P.  tincture)  in  a  teaspoonful  of  water,  every  half  hour  for  3  or  4 
doses.^ 

If  vomiting  occurs  in  spite  of  preliminary  medication  and  anestheti- 
zation by  proper  methods,  one  of  the  oldest  and  simplest  methods  of  re- 
lief is  the  inhalation  of  vinegar  fumes. 

Sometimes  it  may  be  necessary  to  give  a  rectal  injection  of  30  to  40 
drops  of  deodorized  tincture  of  opium  with  60  grains  of  sodium,  bromid, 
to  quiet  the  vomiting  center. 


MANAGEMENT  OF  DIFFICULT  OE  UNUSUAL  CASES 

In  the  foregoing  pages  we  have  considered  the  adjuvant  manage- 
ment of  ordinary  cases — cases  in  which  the  course  of  anesthesia  conforms 
to  what,  from  experience,  one  may  safely  predict;  cases  in  which,  in 
other  words,  the  expected  happens. 

The  anesthetist,  however,  who  settles  himself  comfortably  at  the  head 
of  the  patient,  believing  that  no  dangers  need  be  anticipated  so  long  as 
he  has  observed  the  rules  for  preliminary  medication  and  so  long  as  he  is 
careful  in  his  technique  of  administration,  is  apt  at  any  moment  to  have 
a  rude  awakening,  for  anesthesia  is  no  exception  to  the  general  rule  of 
life,  and  the  unexpected  must  always  be  anticipated.     This  is  true  (1) 

*Am.  J.  Surg.,  4,  152. 

^  The  post-anesthetic  treatment  varies,  of  course,  with  the  nature  of  the  oper- 
ation. 


380  ANESTHESIA 

particularly,  because  of  the  fact  that  individual  susceptibility,  or  insus- 
ceptibility, to  the  given  agent  or  method  of  administration  may  upset  all 
calculations;  (2)  because  a  slight  error  in  technique  may  convert  minor 
difficulties  into  those  of  major  proportions;  (3)  because  the  exigencies 
of  the  surgical  procedure  itself  may  create  unexpected  emergencies  for 
the  anesthetist;  because  latent  or  undiscovered  pathological  conditions 
may  become  complicating  factors. 

The  minor  difficulties  which  may  be  encountered  may  be  grouped  un- 
der the  following  heads : 

(1)  Eespiratory;  (2)  muscular;  (3)  nervous;  (4)  idiosyncratic. 

Eespieatory 

Dyspnea,  hyperpnea,  apnea,  and  stertor  are  among  the  respiratory 
difficulties  most  commonly  encountered.  Some  patients,  particularly 
young  children  and  nervous  women,  persist,  despite  suggestive  therapy, 
in  an  irregular  or  hesitating  manner  of  breathing,  while  others  "hold 
their  breath."  If  allowed  to  go  under  the  anesthetic  in  this  way,  the 
manner  of  breathing  may  characterize  the  stage  of  surgical  narcosis.  In 
some  cases  more  serious  respiratory  disturbances,  even  temporary  respira- 
tory arrest  (apnea),  may  supervene,  calling  for  the  more  heroic  manage- 
ment discussed  hereafter   (see  p.  393). 

A  too  strong  vapor  (chloroform  or  ether)  may  give  rise  to  hesitant 
breathing  after  loss  of  consciousness.  As  a  rule,  safe,  rhythmical  respira- 
tion can  be  induced  reflexly  by  the  manipulation  of  the  lips  (brisk  rub- 
bing with  towel  or  sponge),  or  fauces  (swabbing  out  with  rough  gauze), 
or  other  form  of  peripheral  stimulation. 

The  convulsive  inspiratory  effort  (sobbing)  with  contraction  of  the 
diaphragm  and  spasmodic  closure  of  the  glottis,  particularly  noted  in 
children,  may  lead  to  unpleasant  complications  because  of  the  liability 
to  the  sudden  inhalation  of  too  large  quantities  of  the  anesthetic,  with 
consequent  asphyxia,  or  overdose  symptoms,  varying  according  to  the 
anesthetic  employed. 

If  the  anesthesia  is  begun  while  the  patient  is  still  breathing  in  this 
manner,  the  administrator  must  be  on  guard  and  the  anesthetic  dose 
regulated  accordingly.  If  the  graver  respiratory  manifestations  present 
themselves,  they  must  be  dealt  with  as  hereinafter  indicated. 

In  chloroform  narcosis  one  must  always  be  on  guard  for  so-called 
false  chloroform  anesthesia — early  shallow  breathing  instead  of  aug- 
mented breathing,  which  marks  the  second  stage  in  the  uneventful  cases. 
If  this  be  mistaken  for  a  quickly  induced  surgical  narcosis,  with  com- 
plete loss  of  sensation,  etc.,  and  the  anesthetic  be  continued  and  the 
operation  begun  as  if  this  were  so,  the  patient  may  be  plunged  into  pro- 
found   shock,    calling    for    the    treatment    outlined    in    this    chapter. 


TREATMENT  BEFORE,  DURING,  AND  AFTER  ANESTHESIA     381 

or  the  error  may  be  recognized  and  corrected  by  peripheral  stimulation, 
friction  applied  to  lips,  or  face,  or  hypochondriac  region,  vigorous  rub- 
bing, slapping,  or  pinching. 

Sometimes  in  intranasal  surgery,  sneezing,  of  reflex  origin,  may  oc- 
cur and  persist,  becoming  so  violent  as  to  cause  a  distinct  complication. 
This  can  usually  be  controlled  by  spraying  the  nasal  passages  with  co- 
cain.  Sneezing,  according  to  Hewitt,  may  be  so  violent  as  to  constitute 
a  distinct  difficulty,  especially  in  delicate  operations  about  the  face.'^ 

In  operations  upon  the  intestines,  hiccough,  due  to  some  reflex  irrita- 
tion, may  become  a  disturbing  factor.  If  the  anesthesia  is  initiated 
properly,  and  care  is  taken  to  prevent  an  accumulation  of  mucus  in  the 
fauces,  and  hence  the  swallowing  of  an  undue  quantity  thereof,  this 
phenomenon  is  easily  controlled. 

The  coughing,  retching,  and  vomiting,  minor  difficulties  arising  early 
in  the  administration  from  improper  preparation  of  the  patient  or  from 
imperfect  technique,  may  become  annoying  features  in  the  stage  of  surgi- 
cal narcosis.  Deepening  the  narcosis  will  generally  obviate  these  phe- 
nomena. 

Muscular 

Various  muscular  phenomena  have  been  noted  by  different  observers, 
aside  from  the  struggling  and  other  manifestations  of  muscular  reflexes 
which  accompany  the  stage  of  excitement  as  ordinarily  observed.  Tris- 
mus, or  jaw  spasm,  spasm  of  the  abdominal  muscles,  general  persistent 
muscular  rigidity,  fine  muscular  tremors,  such  as  the  "piano  playing" 
movements  of  chloroform  anesthesia,  the  spasmodic  contractions  of  the 
pectoral  muscles  indicating  slight  asphyxia,  are  all  to  be  met  with  in  ex- 
ceptional cases.  The  various  clonic  muscular  phenomena  may  become  a 
serious  menace  to  life  if  mistaken  for  a  return  to  the  second  stage  of 
anesthesia  (particularly  with  chloroform).  If  the  narcosis  is  deepened 
under  this  misapprehension,  the  patient  may  be  quickly  and  unexpect- 
edly plunged  into  the  stage  of  overdose,  which  may  call  for  vigorous 
measures  of  resuscitation. 

ISTervous 

In  exceptional  cases,  particularly  among  neurotic  subjects,  and  when 
preliminary  medication  has  been  neglected,  the  administration  of  any 
inhalation  anesthetic  may  be  followed  by  the  immediate  onset  of  vio- 
lent insanity.  If  operation  is  imperative  in  such  cases,  it  is  best  to  delay 
the  further  administration  until  narcotic  medication  has  had  time  to 
take  full  effect.     The  anesthetic  should  then  be  given  very  gradually, 

^Hewitt:  '' Anaesthetics, "  1912,  912,  543;  see,  also,  Lancet,  Dec.  2  and  16, 
1893. 


382  ANESTHESIA 

beginning  with  the  essence  of  orange,  if  an  open  method  is  indicated. 
If  a  closed  method,  essence  of  orange  or  nitrous  oxid. 


Idiosyncratic 

It  is  a  well-known  fact  that  some  individuals  cannot  be  operated  upon 
under  local  or  spinal  analgesia.  (See  case  reported  by  Bainbridge,  p. 
623.)  So,  with  inhalation  anesthetics,  very  rare  cases  of  insuscepti- 
bility, apparent  or  real,  are  encountered.  Hewitt  ^  reports  two  cases  in 
which  there  was  insusceptibility  to  nitrous  oxid,  probably  traceable  to 
alcoholism.  He  directs  attention  to  the  point  that  an  acquired  suscepti- 
bility may  be  manifested  in  persons  infected  with  malarial  parasites.  The 
same  author  reports  two  other  cases  in  which  there  was  marked  insus- 
ceptibility. In  one  the  induction  was  begun  with  nitrous  oxid  and  ether, 
with  a  change  to  chloroform,  then  to  ether,  the  C.  E.  mixture  finally 
proving  successful.  In  the  other  case  the  anesthetic  was  begun  with 
ether  by  the  open  method,  without  preliminary  medication.  After  wait- 
ing for  morphin  and  atropin  to  take  effect,  another  effort  was  made,  be- 
ginning with  chloroform  and  switching  to  ether.  Loud  crowing  breath- 
ing lasted  throughout,  but  the  operation  was  completed  successfully. 

Hypersensitiveness,  rather  than  insusceptibility,  it  would  seem,  is  the 
difficulty  to  be  guarded  against. 

There  are  practically  no  minor  difficulties  of  any  unusual  character 
encountered  after  anesthesia. 

Among  the  major  difficulties  which  may  be  encountered  in  the  course 
of  inhalation  anesthesia,  or  the  after-management  of  the  case,  and  which 
directly  concern  the  anesthetist,  are  (1)  shock,  and  (2)  post-anesthetic 
toxemia. 

These  difficulties  undoubtedly  vary  with  the  anesthetic,  with  the  gen- 
eral preliminary  and  concurrent  management  of  the  case,  with  the 
method  of  administration,  with  the  physical  peculiarities  of  the  patient, 
with  the  technique  and  skill  employed  by  the  surgeon,  and  with  preexist- 
ent  pathological  conditions. 

Whatever  the  cause  or  causes,  and  however  these  complications  may 
be  precipitated,  the  anesthetist  must  know  how  best  and  most  expedi- 
tiously to  deal  with  them.  They  are,  therefore,  directly  concerned  with 
the  prognosis  and  treatment  of  the  individual  case,  and  it  behooves  the 
anesthetist  to  be  familiar  with  them  from  the  theoretical,  as  well  as 
from  the  practical,  point  of  view.  In  the  pages  which  follow,  an  attempt 
is  made  to  set  forth,  as  briefly  as  possible,  the  theories,  and  the  views 
with  regard  to  management,  of  those  who,  by  virtue  of  their  original 
observations,  are  best  qualified  to  speak  with  authority.     Whatever  per- 

^ Hewitt:     "Anaesthetics,"  1912,  332,  333;  548,  549. 


TREATMENT  BEFORE,  DURING,  AND  AFTER  ANESTHESIA     383 

sonal  experience  the  authors  have  had  is  merely  corroborative;  we  there- 
fore take  the  liberty  of  drawing  freely  from  those  who  have  concentrated 
effort  in  these  given  directions. 

Shock 

By  far  the  most  important  complication  which  may  arise  in  the 
clinical  experience  of  the  anesthetist  is  shock.  When,  for  any  reason, 
the  patient  emerges  from  the  even  plane  of  a  safe  and  satisfactory  anes- 
thesia into  that  alarming  composite  condition  which  is  designated  as 
shock,  the  anesthetist  must  be  able  quickly  to  marshal  all  his  resources 
toward  the  restoration  of  the  normal  anesthetic  condition. 

Shock  may  be  considered  under  the  four  heads,  according  to  the  chief 
factors  which  induce  it,  of :  ( 1 )  surgical  shock,  that  for  which  the  sur- 
geon is  responsible;  (2)  psychic  shock,  shock  produced  in  a  patient  by 
inability  to  control  the  nervous  system;  (3)  dietetic  shock;  (4)  anes- 
thetic shock,  that  for  which  the  anesthetist  is  responsible. 

Surgical  Shock. — Shock  has  been  described  ^  as  "a  condition  of  gen- 
eral depression  produced  by  various  causes."  With  shock  we  have:  (1) 
a  fall  ill  blood  pressure;  (2)  nerve  centers  react  feebly  to  afferent  stim- 
uli; (3)  pulse  rapid  and  feeble;  (4)  respiration  shallow;  (5)  all  cu- 
taneous reflexes  lessened;  (6)  increased  perspiration,  with  skin  cold  and 
moist ; .  ( 7 )  temperature  lowered ;  ( 8 )  mental  condition  one  of  quiet 
depression,  patient  may  be  conscious  [this,  of  course,  does  not  apply  to 
shock  during  anesthesia]  ;  (9)  no  pain  or  discomfort,  but  a  feeling  of 
weakness. 

Various  factors  are  concerned  in  the  production  of  shock,  and  may 
pertain  as  much  to  the  shock  produced  by  surgical  procedure,  during 
narcosis,  as  when  shock  is  the  result  of  accident  or  any  cause  operative 
under  ordinary  circumstances. 

Keen  ^  gives  these  factors  as  follows : 

"Age. — In  the  new-born,  before  the  physiological  connections  be- 
tween the  great  divisions  of  the  central  nervous  system  have  been  estab- 
lished, it  is  quite  probable  that  at  least  certain  operations  are  very  much 
more  nearly  shock-free  than  they  will  ever  be  again.  (There  is  a  short 
period  of  immunity  that  disappears  with  the  establishment  of  the 
through  paths  of  the  nervous  system).  They  are  not  only  shock-free, 
but  free  from  any  appreciation  of  pain:  In  the  new-born  extensive 
operations  for  cleft  palate  are  endured  without  anesthesia,  pain,  or  shock, 
the  only  immediate  risk  being  hemorrhage.  Within  a  week  or  more 
these  physiological  connections  become  established,  after  which  the  infant 
becomes  even  more  susceptible  to  shock  than  the  adult. 

^ ' '  American  Practice  of  Surgery, "  1,  A  83. 
''Keen's  "Surgery,"  I,  922. 


384  ANESTHESIA 

"Adult  Life. — This  is  the  period  of  greatest  resistan^^e  to  shock. 

"Old  Age. — The  senile  heart  has  an  uncertain  and  limited  range  of 
action.  The  arteries  are  hard  and  the  blood  pressure  is  high.  The  aged 
only  apparently  endure  operations  well.  The  risk  is  determined  not  by 
the  age  of  the  patient,  but  the  age  of  the  circulatory  apparatus.  Toward 
the  completion  of  life's  cycle  the  resistance  to  shock  is  at  a  minimum. 

"Time  of  Day. — The  vital  powers  are  higliest  in  the  morning,  and 
the  psychic  factor  at  a  minimum.  The  most  unfavorable  time  12  to  2 
A.  M.    Autumn  and  early  winter  the  hest.    Summer  the  worst. 

"Occupation. — Professional  and  business  men  are  more  susceptible 
than  the  farmer,  laborer,  and  mechanic.  The  industrious  are  better  sub- 
jects than  the  idle.  The  resistance  of  criminals  is  remarkable.  Soldiers 
and  sailors  are  good  risks;  athletes,  not  so  good;  worst  risk,  overworked 
surgeon  over  50  years  of  age.  Cachectic  patients  bear  operations  poorly. 
In  pernicious  anemia  the  operator's  risk  is  great.  In  chronic  anemia  the 
risk  is  better,  but  still  great.  In  chronic  anemia  from  loss  of  blood  the 
risk  is  better;  in  acute  anemia  from  hemorrhage  the  risk  is  still  better.'^ 

Psychic  Shock. — Psychic  shock  is  "due  to  the  poiverful  impulses  from 
the  highly  specialized  centers  of  the  cerebrum  acting  upon  the  vital  cen- 
ters of  the  medulla."  ,   , 

It  is  hard  to  differentiate  between  prostration  by  fear  and  prostration 
by  injury.  In  most  injuries  the  psychic  and  mechanical  factors  are 
mixed. 

"The  deep  impression  left  upon  the  brain  by  a  powerful  nervous 
shock  often  endures  for  months  and  years." 

Ieritating  Chemicals. — Those  which  cause  marked  irritation  at  the 
point  of  contact  may  produce  shock. 

(According  to  Mummery,  "Burns  of  the  first  and  second  degree  with 
extreme  irritation  only  are  apt  to  cause  more  shock  than  burns  of  the 
third  and  fourth  degree  causing  destruction  of  tissue."  Burns  extend- 
ing over  half  of  the  body  frequently  cause  death  from  shock.) 

Toxic  Causes. — Abscess  breaking  into  the  peritoneal  cavity,  and 
pouring  out  intensely  irritating  chemical  compounds,  causes  shock  by 
intense  local  irritation  and  constitutional  disturbance. 

Mechanical  Causes. — By  mechanical  stimulation  of  nerve  centers 
or  trauma  afferent  impulses  are  sent  toward  the  centers. 

"An  abnormally  low  Hood  pressure  is  the  essential  phenomenon  of 
the  state  commonly  designated  svirgical  shock." 

"Shock  is  the  problem  of  the  various  kinds  of  stimulation  of  the 
nervous  system." 

Susceptibility  of  the  various  tissues  depends  upon  the  quality  and 
quantity  of  their  nerve  supply. 

"A  fall  in  blood  pressure  usually  occurs  while  incising  the  skin  over 
the  abdomen." 


TREATMENT  BEFORE,  DURING,  AND  AFTER  ANESTHESIA     385 

"Asphyxia  is  always  attended  by  a  retarded  pulse  and  slow  and  pow- 
erful respiratory  efforts.  A  fall  in  temperature  is  the  result  of  low  Mood 
pressure." 

Circulation. — The  entire  arterial  system  bleeds  into  the  dilated 
venous  system,  and  the  bulk  of  the  blood  is  not  freely  circulated. 

Eespiration. — It  is  accelerated.  Sighing  and  irregular  or  increased 
action  may  appear.  The  respiration  wave  is  shortened.  Inspiratory  and 
expiratory  efforts  are  quickened,  and  the  pause  is  lengthened.  Later, 
the  gasping  type  of  respiration  with  tracheal  and  chin  tug  indicates  im- 
pending dissolution. 

Muscular  System. — The  voluntary  and  involuntary  muscular  sys- 
tems are  relaxed;  kidney  and  digestive  tract  diminished  in  function; 
skin  relaxes;  pallor  with  consequent  outflow  of  water  or  perspiration. 
Face  is  shrunken,  pinched,  and  elongated;  eyes  lusterless  and  sunken, 
with  lids  only  half  closed;  lips  parted,  thin,  and  pale,  but  may  be  cy- 
anotic; drooping  jaw,  partly  open  mouth,  falling  in  of  cheeks. 

Crile,^  in  his  epoch-making  experimental  researches  concerning  shock, 
made  the  following  observations  concerning  its  production  and  the  re- 
sultant effects.  These  observations  were  made  upon  animals  in  the 
laboratory. 

"Skin. — Cutting  and  tearing  caused  in  the  greater  number  of 
instances  a  rise  of  blood  pressure,  though  sometimes  no  effect  was  ob- 
served. 

"Negative  Eesults. — Kidney,  Spleen,  Bladder,  Eyes. — Mechanical 
injury  caused  usually  no  appreciable  change  in  either  the  circulation  or 
the  respiration. 

"Ears. — As  skin  usually. 

"Mouth. — Crushing,  tearing,  cutting,  and  puncturing  the  tongue 
produced  no  effect  on  either  the  circulation  or  respiration. 

"Heart. — The  slightest  direct  contact  with  the  heart  caused  marked 
changes  in  its  beat  and  in  the  blood  pressure, — a  fall  in  blood  pressure, 
with  short,  irregular  strokes. 

"Diaphragm. — Contact,  however  slight,  with  the  abdominal  side  of 
the  diaphragm  caused  in  every  instance  markedly  arhythmic  respiration. 

"Ahdomen. — In  making  the  incision  through  the  skin  in  the  abdom- 
inal sections  there  was  frequently  noted  a  fall  in  the  blood  pressure ;  this, 
in  fact,  was  the  rule. 

"Cutting  muscles  or  fascia  produced  little  or  no  effect.  On  opening 
the  peritoneum  a  fall  was  noted. 

''Liver. — Manipulation  of  the  gall-bladder  caused  a  marked  tem- 
porary fall. 

"Uterus. — A  rise  in  blood  pressure. 

"Testicles. — A  fall  in  blood  pressure. 

'  Crile,  George  W. :     "An  Experimental  Eesearch  into  Surgical  Shock." 


386  ANESTHESIA 

"Penis. — A  fall  in  blood  pressure. 

"Vagina. — A  rise  in  blood  pressure,  and  increase  in  depth  and  fre- 
quency of  the  respirations. 

"Anus. — Same. 

"Peritoneum. — Contact,  however  slight,  with  the  peritoneum  or  vis- 
ceral peritoiieum  caused  marked  arhythmic  respiratory  action.  The 
diaphragmatic  peritoneum  produced  the  most  marked  respiratory 
changes.  Continuation  of  the  manij)ulation  does  not  secure  tolerance  un- 
less confined  to  the  same  area." 

The  duration  of  an  operation  was  found  to  be  an  important  factor  in 
the  production  of  shock.  Animals  may  be  killed  by  the  effect  of  con- 
tinuous anesthesia  alone,  though  the  anesthetic  is  carefully  administered, 
so  that  a  percentage — calculated  upon  the  ratio  between  the  actual  dura- 
tion of  anesthesia  and  the  average  length  of  time  a  dog  may  survive 
continuous  anesthesia, — is  allowed  for  the  pure  anesthetic  factor  in  any 
given  case ;  that  is  to  say,  if  ten  hours  be  allowed  as  the  average  length  of 
time  a  dog  may  live  under  continuous  anesthesia  and  the  given  experi- 
ment lasted  two  hours,  then  twenty  per  cent  of  the  cause  of  death  was  cal- 
culated to  represent  the  anesthetic  factor.  This  calculation  applies  to 
ether.  There  is  strong  evidence  tending  to  show  that  chloroform,  even 
barring  accidents,  is  a  more  potent  factor  in  destroying  the  animal  than 
is  ether. 

Contact  with  air  is  a  very  great  irritant  to  local  tissues,  owing  to  the 
lowering  of  local  temperature  and  to  the  drying.  Exposure  of  the 
thoracic  cavity  causes  great  disturbance  of  respiration,  and  the  time  of 
exposure  should  be  as  short  as  possible.  "The  element  of  time  in  ab- 
dominal operations  in  every  experiment  was  unmistakable." 

Temperature. — The  effect  on  the  intestines  of  cold  water  and  of  the 
intravenous  cold  saline  solution  showed  more  directly  the  depressing  in- 
fluences of  the  cold.  The  direct  effect  of  warm  towels  applied  to  the  ex- 
posed intestines,  of  warm  saline  in  the  abdomen,  improved  the  respira- 
tion immediately,  and  as  nearly  as  could  be  estimated  caused  at  least 
a  check  in  the  declining  blood  pressure. 

Anesthesia. — The  respirations  in  over-anesthesia  became  generally 
more  shallow  and  slower,  and  if  the  anesthetic  was  continued  would  fail 
suddenly.  The  blood  pressure  pari  passu  gradually  fell.  Upon  removing 
the  ether  both  would  rise,  much  as  they  fell.  The  respiratory  indica- 
tions were  usually  in  advance  of  any  other  symptom  in  foretelling  the 
tendency  of  the  anesthesia.  The  effect  upon  respiration  was  so  constantly 
in  advance  of  other  effects,  for  example,  that  upon  the  circulation, 
that  the  latter  was  habitually  neglected.  Ether  in  no  instance  caused 
sudden  cardiac  arrest ;  chloroform,  three  times,  each  time  early  in  the  in- 
halation and  before  surgical  anesthesia  had  been  induced.  Chloroform 
proved  to  be  more  toxic  than  ether.     Over-anesthesia  rendered  the  ani- 


TREATMENT  BEFORE,  DURING,  AND  AFTER  ANESTHESIA     387 

mals  subject  to  early  collapse  and  decidedly  less  capable  of  withstanding 
a  protracted  experiment. 

Hemor7-hage. — Loss  of  blood  always  predisposes  to  shock.  Eespira- 
tions  are  always  accelerated  and  deepened  in  profuse  hemorrhage. 
Hemorrhage  from  the  large  venous  trunks  caused  the  most  pro- 
found effect  upon  the  blood  pressure,  because  the  quantity  of  blood 
supplied  to  the  heart  was  immediately  diminished,  while  if  the 
hemorrhage  was  arterial  the  income  of.  blood  was  not  so  suddenly 
diminished.^ 

Dietetic  Shock. — Chauvin  and  fficonomos  ^  state  that  disturbances  of 
metabolism  are  observed  regardless  of  the  anesthetic,  or  method  of  ad- 
ministration, whether  local,  spinal,  or  general.  This  "dietetic  shock"  is 
due  to  fasting  immediately  preliminary  to  and  following  anesthesia.  This 
shock  can  be  avoided  by  the  use  of  glucose,  150  gm.,  tincture  of  cinna- 
mon, 6  gm.,  and  tincture  of  nux  vomica,  0.59  gm.  and  water  to  make  300 
gm.,  or  some  other  easily  digested  carbohydrate  diet.  When  this  mixture 
was  taken  the  day  before  and  the  three  days  following  the  operation,  the 
urine  showed  no  pathologic  changes  such  as  occurred  when  this  regime 
was  not  followed. 

Anesthetic  Shock. — In  the  preceding  pages  we  have  discussed  shock 
from  the  surgical  and  theoretical  points  of  view.  We  come  now  to  the 
consideration  of  shock  caused  by  the  anesthetist,^  independently  of  the 

^According  to  J.  Am.  Med.  Assn.,  June  14,  1913,  in  post-partum  hemorrhage 
the  patient  may  survive  a  loss  of  about  half  of  the  total  amount  of  the  blood  in 
the  body.  Whether  or  not  this  conclusion  is  applicable  to  other  forms  of  acute 
loss  of  blood  is  not  definitely  determined,  but  it  is  probably  not  far  out  of  the 
way. 

^Chauvin,  E.,  and  CEconomos,  S.  N. :  "Necessity  for  Avoiding  Dietetic  Shock 
in  Operative  Cases,"  Bevue  de  Chir.,  Paris,  Mar.,  33,  No.  3. 

^  Shock,  hemorrhage,  and  the  anesthetic  are  closely  related,  according  to 
French:  "In  the  testing  work  in  anesthesia  the  writer  has  had  foremost  in 
mind  the  great  need  of  reducing  shock.  It  is  generally  conceded  that  the  child 
is  more  susceptible  to  shock  than  the  adult,  due,  in  some  way,  no  doubt,  to  the 
fact  that  the  child  is  anatomically  and  physiologically  different  from  the  adult. 
The  tests  have,  therefore,  been  applied  especially  to  children  in  the  controlling 
of  hemorrhage  and  in  the  administration  of  anesthetics.  We  find  no  variance 
from  the  belief  among  surgeons  who  have  given  careful  thought  to  their  work 
upon  infants  and  children,  that  the  losing  of  blood  is  a  matter  of  the  greatest 
import  to  them  and  that  all  means  should  be  used  to  prevent  hemorrhage  in 
operating  upon  them.  And  we  are  now  convinced  that  shock  from  the  loss  of 
blood  and  from  the  anesthetic  can  be  materially  reduced  by  the  manner  of  admin- 
istering the   anesthetic. 

' '  According  to  the  observations  of  the  writer  of  this  paper  there  is,  irrespec- 
tive of  all  other  conditions,  a  well  defined  and  never  failing  relationship  between 
the  degree  of  skill  in  which  a  patient  is  anesthetized  in  the  upright  position  and 
the  amount  of  hemorrhage  which  occurs  during  the  anesthesia,  for  there  seems  to 
be  no  question  but  that  hemorrhage  is  reduced  if  the  anesthetic,  from  the  be- 
ginning,  is   smoothly   administered,   the    second    stage    omitted,    and   the   patient 


388  ANESTHESIA 

surgical  procedure  The  subject  is  partly  covered  in  the  discussion  of  the 
fourth  stage,  or  the  stage  of  overdose,  of  each  of  the  inhalation  anesthetic 
agents.  Other  factors,  however,  besides  overdose,  may  enter  into  the 
production  of  anesthetic  shock.  These,  together  with  the  treatment  of 
the  condition,  however  it  may  be  produced,  are  considered  in  the  fol- 
lowing pages. 

Anesthetic  shock  may  be  produced  in  three  ways:  (1)  By  giving 
an  overdose  of  the  anesthetic;  (2)  by  maintaining  too  light  an  anes- 
thesia; (3)  by  failing  to  keep  an  open  airway.  We  will  discuss  these 
briefly,  seriatim. 

Shock  Caused  by  Giving  aist  Overdose  of  the  Anesthetic. — It 
has  been  stated  that  the  liability  of  shock  from  an  overdose  of  the  anes- 
thetic varies  with  the  subject,  with  the  method  of  administration,  with 
the  agent  employed,  and  with  various  other  factors.  The  signs  of  over- 
dose have  been  given  under  each  inhalation  anesthetic,  respectively,  and 
need  not  be  reiterated  here. 

With  nitrous  oxid,  if  a  slight  degree  of  asphyxia,  by  delimiting  the 
supply  of  air  or  oxygen,  is  maintained  throughout  a  long  operation,  this, 
in  itself,  is  apt  to  produce  a  state  of  shock.  This  is  all  the  more  apt  to 
occur  if  a  certain  amount  of  shock  has  been  caused  through  the  manipu- 
lation of  the  surgeon,  or  through  hemorrhage.  This  combination  of 
circumstances  may  lead  to  complete  shock,  calling  for  the  measures 
of  resuscitation  described  under  Surgical  Shock,  provided  the  im- 
mediate withdrawal  of  the  anesthetic  and  the  restoration  of  carbon 
dioxid  balance,  in  accordance  with  the  theory  of  Henderson,  are 
not  sufficient  to  restore  respiration  and  circulation  to  a  plane  of 
safety. 

With  ether  the  chief  danger  of  shock  from  an  overdose  is  caused  by 
the  maintenance  of  too  deep  an  anesthesia  during  a  long  and  difficult 
operation.  Such  a  state  of  affairs  always  calls,  primarily,  for  lightening 
the  anesthesia.  If  this  is  not  sufficient,  other  methods  described  else- 
where should  be  employed. 

With  ethyl  chlorid  it  is  to  be  remembered  that  shock  from  overdose 
is  especially  liable  to  occur  with  a  careless  or  inexperienced  adminis- 
trator, for  the  reason  that  anesthesia  is  so  rapidly  induced  that  the 

brought  into  full  surgical  anesthesia  without  jarring  or  body  disturbance  of 
any  kind.  The  uniform  employment  of  helpful  mental  suggestion  by  every  in- 
dividual in  contact  with  the  patient  up  to  the  time  of  the  induction  of  anesthesia, 
to  assist  in  preventing  an  excessive  discharge  of  nervous  energy  through  fear — 
which  is  one  of  the  elements  in  the  '  anoci-association '  of  Crile ;  the  administra- 
tion of  morphin  to  patients  who  display  a  marked  degree  of  apprehension;  an 
anesthetizing  room  free  from  an  atmosphere  of  excitement  and  from  unneces- 
sary noise ;  the  preliminary  use  of  nitrous  oxid  or  the  essence  of  orange. ' ' 
French,  Thomas  E. :  "Nitrous  Oxid,  Essence  of  Orange,  Ether  and  Sequestra- 
tion in  General  Anesthesia."    N.  Y.  Med.  J.,  May  24,  1913. 


TREATMENT  BEFORE,  DURING,  AND  AFTER  ANESTHESIA     389 

border  line  between  safety  and  danger  may  be  quite  easily  passed.  This 
is  particularly  true  because  of  the  fall  in  blood  pressure  which  always 
accompanies  anesthesia  by  this  agent.  In  the  presence  of  the  signs  of 
shock  already  stated,  if  immediate  withdrawal  of  the  anesthetic  does 
not  revive  the  patient,  the  more  active  measures  must  be  quickly  insti- 
tuted. 

With  cidoroform  it  is  more  dangerous  to  keep  the  patient  under  deep 
surgical  anesthesia  than  with  any  other  agent,  except,  perhaps,  ethyl 
chlorid.  The  shallow  respiration,  weak,  thready  pulse,  sudden  and  com- 
plete dilatation  of  the  pupil,  and  extreme  pallor  of  the  face  are  the 
danger  signals  which,  separately  or  combined,  should  put  the  anes- 
thetist on  his  guard.  At  times  the  anesthetic,  in  conjunction  with 
the  surgical  iDrocedure,  brings  about  a  condition  of  shock  with  start- 
ling suddenness.  Withdrawal  of  the  anesthetic  may  answer  the  pur- 
pose, but  it  is  more  than  probable  that  more  heroic  measures  will  be 
necessary. 

Shock  During  Light  Anesthesia. — This  form  of  shock  is  espe- 
cially seen  during  laparotomies  in  which  the  patient  has  been  too  hastily 
or  improj)erly  anesthetized  and  the  surgeon  begins  the  operation  before 
full  surgical  anesthesia  is  reached. 

We  will  suppose  the  patient  just  beyond  the  second  stage,  but  not  in 
full  surgical  anesthesia.  In  this  condition,  if  the  operation  is  a  lapa- 
rotomy, every  tng  upon  the  viscera  will  increase  the  respiratory  effort. 
If  this  hyperpnea  is  kept  up  during  the  entire  period  and  the  operation 
is  a  lengthy  one,  it  will  result  in  acapnia,  and  thus  finally  affect  the  circu- 
lation. 

If  the  patient  is  already  in  a  reduced  condition  there  is  a  possibility, 
of  this  condition  being  a  serious  one. 

If  the  operation  is  upon  an  extremity,  where  no  important  vessels  or 
nerves  are  involved,  the  chances  for  a  dangerous  degree  of  shock  are  ma- 
terially lessened. 

Shock  from  an  Obstructed  Airway. — The  space  between  the  ex- 
ternal respiratory  orifices  and  the  epiglottis  has  been  very  properly  called 
by  Meltzer  the  "death  space,"  inasmuch  as  this  part  of  the  respiratory 
tract  causes  more  trouble  to  the  anesthetist  than  everything  else  com- 
bined. 

Shock  may  be  caused  from  allowing  a  slight  degree  of  cyanosis 
throughout  a  long  operation,  this  being  caused  by  allowing  a  more  or 
less  continuous  interruption  to  the  breathing.  Shock  is  more  often 
caused  in  this  way  than  is  commonly  supposed. 

Obstruction  hy  Closure  of  the  Alee  of  the  Nose. — In  elderly  people 
especially,  or  in  very  weak  or  nervous  individuals,  obstruction  of  the  air 
passages  by  closure  of  the  alse  is  not  an  unusual  thing.  It  is  easily  pre- 
vented by  placing  rubber  tubing  of  convenient  size,  about  an  inch  and  a 


390  ANESTHESIA 

half  long,  in  each  nostril,  allowing  the  ends  to  project  a  quarter  to  half 
an  inch  outside.  This  condition  may  also  be  remedied  by  manipulating 
the  lower  jaw  in  such  a  way  that  the  patient  is  compelled  to  breathe 
through  the  mouth  instead  of  the  nose. 

Shock  from  Labial  Stertor. — A  dangerous  degree  of  shock  from  this 
source  is  not  apt  to  occur  because  this  form  of  stertor  is  so  objectionably 
apparent  to  all  present  that  it  is  usually  quickly  remedied  if  the  open 
method  is  in  use.  It  may  cause  serious  trou^ble  if  the  closed  method  is 
being  used  and  the  anesthetist  is  unable  to  observe  the  lips  of  the  pa- 
tient. This  condition  is  modified  by  pressing  the  jaw  upward  and  at  the 
same  time  slightly  forward.  Also  by  placing  the  end  of  a  towel  or  a  piece 
of  gauze  between  the  lips. 

Closure  of  the  Glottis  by  the  Tongue  Dropping  Back. — This  is  the 
most  common  form  of  stertor  met  with,  and  is  fortunately  remedied 
very  easily.  It  is  caused  by  the  relaxation  of  the  muscles  supporting  the 
tongue  as  the  patient  reaches  the  third  stage  of  anesthesia.  The  tongue 
drops  back,  thus  closing  or  partially  closing  the  glottis.  Tongue  stertor 
may  be  caused  in  the  beginning  of  the  anesthesia  by  failure  of  the  anes- 
thetist to  remove  the  pillow,  or  anything  that  may  be  under  the  patient's 
head,  or  by  allowing  the  head  to  remain  in  a  straight  line  with  the  body, 
instead  of  having  it  turned  either  to  the  right  or  left  side.  There  are  a 
small  number  of  patients  who  breathe  better  when  the  head  is  propped 
up  and  the  chin  pressed  in,  but  these  are  the  exceptions.  The  vast  ma- 
jority of  patients  breathe  much  better  in  full  surgical  anesthesia  with 
the  head  on  the  same  horizontal  plane  with  the  body,  and  also  turned 
slightly  to  one  side.  This  does  not  apply  to  obese  patients  with  a  short 
neck.  These  patients'  heads  should  be  supported  in  such  a  way  that  no 
"effort  is  thrown  upon  the  neck  muscles. 

Respirations. — If  a  patient's  respirations  are  perceptibly  increased  or 
interfered  with  by  a  closed  method,  and  it  is  impossible  to  maintain  an 
even  anesthesia  in  this  way,  a  change  to  the  open  method  should  imme- 
diately be  made. 

Many  anesthetists  use  an  artificial  airway  during  surgical  anesthesia. 
Ferguson's  description  of  the  original  Hewitt's  airway  and  his  own  fol- 
lows: 

"Hewitt's  airway  (Fig.  138)  consists  of  a  somewhat  rigid  rubber 
tube,  C,  curved  so  that,  when  it  is  in  position  in  the  patient's  mouth, 
it  will  conform  to  the  upper  aspect  of  the  base  of  the  tongue.  It  has 
its  laryngeal  end  beveled  to  correspond  with  the  opening  into  the 
larynx.  At  the  proximal  end  a  metal  funnel-shaped  mouthpiece  is 
attached.  Figure  138  B.  This  has  a  deep  groove  so  as  to  enable  it 
to  be  clutched  by  the  teeth  in  order  to  hold  it  in  position.  The 
tube  is  introduced  into  the  pharynx  and  respiration  takes  place  through 
it. 


TREATMENT  BEFORE,  DURING,  AND  AFTER  ANESTHESIA     391 


Fig.    138. — Hewitt's    Artificial    Airway. 


"Fer^ison's  modification  of  Sir  Frederick  Hewitt's  airway,  Figure 
139,  differs  from  its  predecessor  in  having  tlie  proximal  end  of  the 
funnel  closed  (Fig.  139,  D)  aud  two  openings  (one  on  each  side  of  the 
truncated  cone)  for  the  ingress  and  egress  of  air,  Figure  139,  E.  Thus 
there  can  be  no  danger  of  dropping  ether  into  the  top  of  the  funnel, 
because  it  is  not  open,  and  since  the  orifices  are  in  the  sides  which 
slope  toward  the  lumen  of  the 
tube,  and  therefore  away  from 
the  source  of  dropping,  it  is 
almost  impossible  to  get  any 
ether  into  the  tube.  Should 
the  patient's  cheek  be  resting 
on  the  table,  any  ether  that 
might  enter  the  upper  fenestra 
would  pass  across  the  funnel 
and  out  of  the  lower  fenestra, 
so  that  it  is  almost  impossible 
for  any  liquid  ether  to  enter 
the  airway,  no  matter  what 
the  position  of  the  patient 
may  be. 

"Ferguson  lengthened  and 
otherwise  changed  the  metal  thimble   (Fig.  138,  F)   so  that  it  extends 
well  into  the  rubber  tube  C  Avithout  enlarging  the  middle  of  the  tube 
(Fig.  139,  G).     Consequently  a  patient's  teeth  may  clutch  the  rubber 
tube  C  anywhere  between  G  and  the  groove  near  E    (Fig.   139)    and 

the  inside  metal  tube  will  re- 
sist the  pressure  and  the  lu- 
men of  the  airway  remain 
open. 

"This  airway  should  be  in- 
troduced after  surgical  anes- 
thesia has  been  reached.  If 
the  patient  is  not  well  under 
the  anesthetic,  the  contact  of 
the  tube  with  the  pharyngeal 
wall  may  incite  gagging.  To 
adjust  the  airway  the  jaws 
should  be  separated,  the 
tongue  brought  gently  for- 
ward, and  the  airway  passed 
back  into  the  pharynx  with 
the  convex  portion  of  the  curved  rubber  tube  nearest  the  roof  of  the 
mouth.     The  instrument  of  itself  will  then  assume  a  proper  position. 


Fig. 


139. — Ferguson's     Modification     of 
Hewitt's  Artificial  Airway. 


392 


ANESTHESIA 


The  pharyngeal  tube  is  useful  to  do  away  with  respiratory  embarrass- 
ment due  to  any  form  of  occlusion  of  the  extrapharyngeal  respiratory 
tract."  1 

Connell's  Breatlimg  Tube. — Connell's  breathing  tube  (Fig.  140)  is 
a  flattened  copper  tube  curved  to  fit  the  roof  of  the  mouth,  easy  of  in- 
troduction. It  provides  for  the  minimum  displaceinent  of  oral  struc- 
tures and  abundant  free  gas  channel  from  the  outer  world  to  the  lower 
pharynx.  This  tube  is  used  in  ordinary  anesthesia  with  any  face  mask. 
An  attachment  at  the  end  of  this  tube  permits  the  placing  of  a  re- 
breathing  bag  fitted  with  a  stopcock  at  the  distal  end.  Rebreathing  may 
be  regulated  by  this  stopcock.  A  rubber  dam  is  placed  on  this  pharyn- 
geal tube  and  so  adjusted  between  the  gums  and  lips  as  to  make  an  air= 
tight  joint. 


Fig.  140. — Connell's  Breathing  Tube.  A  flattened  metallic  tube  curved  to  fit 
the  palate  and  pharynx.  Provides  a  free  non-collapsible  airway  without  dis- 
placement of  oral  structures. 


With  the  placing  of  any  breathing  tubes,  or  the  maintenance  of 
a  free  airway  by  other  methods,  the  stertor  due  to  the  anesthetic  is 
eliminated. 

Treatment  of  Anesthetic  Shock." — When  the  pulse  disappears 
and  the  respirations  become  very  shallow  or  cease,  in  the  absence  of 
cause  for  suspecting  surgical  shock,  the  anesthetist  may  know  that  ho  is 
to  blame  for  the  condition.  He  must  be  able  to  quickly  judge  the  par- 
ticular error  of  technique  which  has  brought  about  the  state  of  shock,  and 
to  correct  this  error  accordingly.  If  withdraAving  the  anesthetic,  deepen- 
ing the  narcosis,  or  restoring  openness  of  airway  fail  to  revive  the  pa- 
tient, certain  other  measures  must  be  resorted  to,  according  to  the  sever- 
ity of  the  shock.  (1)  A  quick,  vigorous  slap  on  the  chest;  (2)  imme- 
diate lowering  of  the  head.  If  the  subject  is  an  infant,  it  should  be 
suspended   by   the   heels;    (3)    dilatation   of   the   sphincter  ani;    (4) 

^J.  Am.  Med.  Assn.,  June  14,  1913. 
^For  Eesuscitation   by  Electricity,   see  Chapter  XVI. 


TREATMENT  BEFORE,  DURING,  AND  AFTER  ANESTHESIA     393 


the  application  of  hoi  or  cold  cloths  to  the  face.  \i  these  simpler 
measures  do  not  suffice;  one  must  resort  to  (5)  artificial  respiration. 
This  is  accomplished  hy  various  methods,  some  of  which  are  given 
below. 

Artificial  Respiration  hy  Manual  Means. —  (1)  The  anesthetist 
grasps  the  arms  of  the  patient  near  the  elbows,  and  presses  them  firmly 
against  the  sides,  thus  expelling  any  chloroform  vapor  that  may  be  in 
the  air  passages.  The  arms  should  be  held  tightly  against  the  patient's 
sides  for  at  least  fifteen  seconds.  (3)  They  should  then  be  drawn  laterally 
below  the  head  and  held  in  this  position  for  ten  or  fifteen  seconds.  This 
procedure  should  be  repeated  fifteen  times  a  minute.  Massage  of  tlie 
precordial  region  by  an  assistant  is  most  helpful,  as  is  also  intermittent 
dilatation  of  the  sphincter.  Hypodermics  do  little,  if  any,  good  at  this 
time.  It  is  the  anesthetist's  duty  to  see  that  an  open  airway  is  maintained 
during  this  procedure.  The  mouth  gag  should  be  inserted  and  the 
tongue  forceps  applied,  and 
the  tongue  pulled  well  for- 
ward, if  there  is  any  occlu- 
sion of  the  air  passages. 
Traction  of  the  tongue 
sometimes  stimulates  the 
respiration.  (3)  If  none 
of  these  efl^orts  is  successful 
and  the  patient  is  in  a  state 
of  collapse,  the  following 
method  of  Lewis  ^  should 
be  tried: 

Lewis  "P  en  clulum 
Swing." — "The  patient 
should  be  suspended  by  the 
fully  flexed  knees  and  swung 
forcibly  from  side  to  side 
for  a  period  of  from  one  to 
two  minutes.  Suspension  is 
best  accomplished  by  the 
operator's    forearms    so 

grasping  the  patient's  knees  as  to  hold  the  anterior  surface  of  both  legs 
against  operator's  chest,  allowing  dependence  of  thighs,  trunk,  arms,  and 
head  of  patient,  facing  away  from  operator.  Except  in  children  it  is 
necessary  for  the  operator  to  stand  upon  a  dais,  box,  or  chair  of  sufficient 
height  to  permit  full  pendulum  swing  of  the  patient  from  side  to  side 
without  contact  of  patient's  arms  or  head  with  the  floor.  Swinging 
should  be  done  as  vigorously  as  possible  to  secure  by  centrifugation  a 

^ Lewis,  Eugene  Richards:     In  a  private  communication. 


Fig.  141. — The  Lewis  Pendulum  Sw^ng. 


394  ANESTHESIA 

forcible  distention  of  heart  and  intracranial  vessels.  The  suffusion  of 
neck  and  face  which  is  brought  on  by  this  swinging  is  the  index  by 
which  to  judge  the  effect  of  centrifugation.  Notes  on  several  cases 
follow. 

"September  1,  1899,  male,  15  years,  brought  to  Wilkes-Barre  City 
Hospital  with  dislocation  of  right  femur,  20  hours'  standing.  Physical 
examination  negative ;  chloroform  was  administered ;  patient  resisted  con- 
siderably and  suddenly  ceased  breathing.  Usual  measures  and  artificial 
respiration  continuously  for  over  ten  minutes,  during  which  time  strych- 
nin and  atropin  were  administered  hypodermically,  but  failed  to  re- 
establish respiration.  We  then  attempted  to  restore  the  patient  by  in- 
creasing the  volume  of  blood  in  head,  neck,  and  chest,  using  forcible 
centrifugation  to  accomplish  this.  Accordingly  the  patient  was  grasped 
by  the  knees,  and  was  swung  to  and  fro,  sideways  with  all  possible  force, 
until  there  was  manifest  a  deep  suffusion  upon  neck  and  head.  The 
patient  was  then  placed  upon  the  table,  and  was  found  to  be  breathing 
spontaneously.  Chloroform  was  continued  cautiously,  and  reduction  of 
the  dislocation  was  effected. 

"In  July,  1901,  at  Wills  Eye  Hospital,  Philadelphia,  service  of  Dr. 
Eadcliffe,  case  for  squint  operation.  Chloroform  was  given,  with  early 
collapse  and  cessation  of  respiration.  Slapping  chest,  cold  douching, 
atropin,  and  strychnin  hypodermically  and  artificial  respiration  all  failed 
to  restore  breathing.  After  about  four  minutes,  patient  was  swung  as 
above  described,  until  marked  suffusion  of  face  and  neck  occurred ;  spon- 
taneous respiration  was  reestablished. 

"Trinity  Hospital,  Milwaukee,  service  of  H.  V.  Wurdemann,  Jan- 
uary 28,  1902,  Patterson,  medical  student,  22  years,  for  brossage  of 
lids  and  canthoplasty.  Physical  examination  negative.  Chloroform 
anesthesia,  collapse  and  cessation  of  respiration  before  beginning  of 
operation.  After  three  minutes  of  ineffectual  attempts  to  revive  the 
patient,  he  was  swung  vigorously  till  face  and  neck  were  well  suffused, 
resulting  in  establishing  spontaneous  respiration.  Operation  was 
thereupon  completed  under  chloroform  anesthesia  without  further 
trouble. 

"In  1903  or  1904  chloroform  was  given  in  a  case  of  tonsillect- 
omy. Collapse  occurred  and  respiration  ceased.  Douching,  slapping 
chest,  stretching  sphincter  ani  and  artificial  respiration  for  four 
or  fi.ve  minutes  failed  to  revive  patient.  Swinging  for  about  45  sec- 
onds succeeded  in  establishing  spontaneous  respiration  without  further 
trouble. 

"March  29,  1911,  Max  L.,  8  years,  brought  to  Mercy  Hospital  from 
Wisconsin.  Hypertrophic  tonsils  and  adenoids.  Physical  examination 
negative.  Chloroform  was  given,  patient  somewhat  nervous,  but  resisted 
very  little.    Early  in  narcosis,  before  loss  of  all  reflexes,  patient's  respira- 


TREATMENT  BEFORE,   DURING,  AND  AFTER  ANESTHESIA     395 

tion  suddenly  l)ecame  superficial  and  then  stopped  entirely.     Very  slight 
grade  of  cyanosis  followed  by  a  sudden  marked  pallor  with  radial  and 


Fig.   142  a. — Artificial  Respiration.     First  Movement. 

temporal  pulse  not  palpable;  widely  dilated  pupils.     Artifical  respira- 
tion with  lowered  head  was  ineffective.     Dilating  sphincter  gave  no  re- 


FiG.  142  B. — Artificial  Respiration.     Second  Movement. 


sponse  whatever.     Amyl  nitrite  was  useless  because  patient's  respiration 
had  ceased.    The  patient  was  now  grasped  under  flexed  knees  and  swung 


396  ANESTHESIA 

from  side  to  side  with  considerable  force,  much  the  same  as  one  might 
swing  an  asphyxia  livida  at  birth.  A  pale  cyanosis  soon  appeared  about 
the  mouth;  respiratory  movements,  at  first  shallow  and  irregular,  could 
be  made  out,  and  soon  spontaneous  respiration  was  established.  The 
force  of  the  heart  beats  remained  irregular  for  at  least  an  hour,  and  a 
circumoral  pallor  was  present  for  at  least  two  hours.  The  operation  was 
performed  the  following  day,  ether  as  anesthetic,  with  no  return  of  symp- 
toms of  day  before. 

"April  19,  1911.  Well-built  girl  of  24  years,  weight  about  150 
pounds.  Chloroform  as  anesthetic.  Did  not  struggle,  but  refused  to 
breathe  anesthetic  quietly  and  regularly.  Had  reached  a  deeper  stage 
of  narcosis  than  preceding  patient.  Failure  of  respiration  came  on  sud- 
denly, but  pulse  remained  fair.  Cyanosis  became  marked.  Artificial 
respiration,  camphorated  oil,  ammonia  hypodermically,  with  stretching 
of  sphincter  ani  failed.  Eesuscitation  was  now  attempted  by  swinging  the 
150-pound  patient  as  above  described.  Since  this  was  primarily  and 
entirely  respiratory  failure,  the  reaction  following  suspension  and  swing- 
ing was  all  the  more  marked.  The  operation  Avas  sucessfully  completed 
with  ether,  after  resuscitation." 

Apparatus  for  the  Induction  of  Artificial  Respiration. — It  cannot  be 
too  strongly  emphasized  that,  no  matter  how  efficient  may  be  a  given 
apparatus  for  the  maintenance  of  artificdal  respiration,  when  the  exi- 
gency arises  no  time  must  be  lost  while  the  apparatus  is  being  put  in 
place.  It  is  necessary,  therefore,  to  resort  to  one  or  more  of  the  meas- 
ures for  the  induction  of  artificial  respiration  described  in  the  foregoing 
pages,  while  the  mask  is  being  placed  upon  the  face,  or  the  tubes  into 
the  pharynx  or  trachea,  as  the  case  may  be.  JSTor  should  such  measures 
be  discontinued  until  the  apparatus  is  working — in  other  words,  until  air 
is  being  forced  into  the  lungs. 

Draeger's  Pulmotor. — The  Draeger  pulmotor  is  being  used  with 
great  success.  It  will  not  overdistend  a  small  lung,  und  will  fully  dis- 
tend the  adult  lung.  It  works  automatically,  adapting  itself  to  the  ca- 
pacity   of    the 


lung.      The   dif- 
ferent parts,  and 

V     9-f/ 

the    manner    of 
application,     are 
illustrated    and 
explained  in  the 

=^ 

c.  "^'^Jpj  1 

""ts 

h 

a  c  CO  mpanying 
figures. 
Preliminaries. — 

■""                  — 

--- 

1.  Eemove  the 

Fig.  143a. 

clothing    from 

TREATMENT  BEFORE,   DURING,  AND  AFTER  ANESTHESIA     397 


Fig.   143b. 


Fig.  143c. 


the  upper  part  of  the  patient's  body.  In  cases  of 
drowning,  lay  the  patient  face  downward,  on  a 
support  that  raises  the  abdomen,  and  apply  pres- 
sure to  the  back  so  as  to  make  the  water  rush  out 
of  the  lungs  and  stomach. 

2,  Free,  the  mouth  and  throat  from  mucus, 
preferably  by  means  of  a  cloth  wrapped  round 
the  forefinger. 

3.  The  unconscious  patient  should  be  laid  on  his  back,  and  the- 
shoulders  raised  by  means  of  a  folded  garment,  leaving  the  head  well 

thrown  back. 

4.  To  enable  the 
air  to  gain  free  ac- 
cess to  the  lungs, 
the  tongue  should 
be  gripped  with  the 
forceps  provided 
for  that  purpose,  and  then  draAvn  forward  as  far  as  it  will  come,  and 
held  in  that  position. 

Placing  the  Pulmotor  in  Position. — 5.  The  pul- 
motor  mask  must  be  buckled  firmly  to  the  head, 
leaving  the  tongue  projecting  between  the  lower 
jaw  and  the  edge  of  the  mask.  The  flexible  tubes 
should  rest  on  the  forehead,  not  over  the  mouth. 
Take  care  that  the  mask  fits  airtight.  This  can  be 
accomplished  by  bending  the  edge  of  the  mask  and 
tightening  its  two  straps. 

The  lower  jaw  must  not  be  forced  back  (down- 
ward). If  necessary,  it  should  be  pushed  forward, 
by  means  of  the  manipulation  illustrated  in  Figure  143D,  to  such  an 

extent  that  the  teeth  in  the 
lower  jaw  project  beyond  those 
of  the  upper  jaw,  not  forget- 
ting to  keep  the  tongue  firmly 
drawn  out. 

6.  The  lever  U  of  the  ap- 
paratus should  be  moved  into 
the  position  marked  "Pul- 
motor," and  the  valve  of  the 
oxygen  cylinder  V  opened.  If 
the  passage  to  the  lungs  is 
open,  and  the  mask  fits  air- 
tight, respiration  will  com- 
FiG.  143e.  mence. 


Fig.  143d. 


398 


ANESTHESIA 


Fig.   143f. 


If  this  does  not  occur,  and  the  apparatus  is 
found  to  reverse  too  quickly,  and  to  continue  doing 
so,  it  is  a  sign  that  the  passage  to  the  lungs  is  not 
free.  In  such  event,  remove  the  mucus,  draw  the 
tongue  further  out  and  push  the  lovs^er  jaw  for- 
ward. 

If  the  apparatus  does  not  reverse  at  all,  then  the  mask  is  not  fitting 
tight.     (See  5.) 

If  necessary,  the  pulmotor  can  be  made  to  pulsate  (delivery  and  suc- 
tion strokes)  by  hand.     (See  8.) 

The     Pulmotor     in     Operatio  n. — 7.      The     air     forced 
in    and    out    of    the    body    by     the    pulmotor    should    pass    only    into 


Fig.  143g. 


the    lungs,    and    not    into    the    stomach.      In    order    to    insure    this 
and   to   close   the  esophagus,    the   manipulation    devised   by    Dr.    Eoth 


Fig.   143h. 


Fig.  143i. 


TREATMENT  BEFORE,   DURING,  AND  AFTER  ANESTHESIA     39'J 


of  Liibeck,  consisting  in  the  application  of  finger  pressure  to  the  Adam's 
apple  of  the  throat,  is  practiced.  Two  fingers  are  gently  pressed  on  the 
middle  of  the  throat  against  the  windpipe,  Avhich,  being  firm,  closes  the 
underlying  esophagus,  and  thus  completely  prevents  access  to  the 
stomach. 


Fig.  143j. 

8.  If,  from  any  cause,  respiration  should  not  go  on  automatically, 
the  pulmotor  may  be  reversed  by  hand,  by  moving  the  small  lever  H 
to  and  fro,  the  lever  being  firmly  held  all  the  time. 

The     Lungmotor. — T  he  _ 

lungmotor  is  a  device  operated 
by  hand,  with  notched  grada- 
tions for  different  ages,  as 
shown  in  Fig.  144.  It  does  not 
depend  upon  back  pressure  in 
the  lungs,  but  exhausts  the  air 
upon  expiration.  The  advan- 
tages claimed  for  it  are  that  it 
requires  less  physical  labor 
than  manual  methods,  and  de- 
livers a  positive  volume  of  air 
with  each  movement.  It  is 
available  for  persons  of  all 
ages  and  correspondingly  vary- 
ing lung  capacities. 

Meltzers  Devices  for  Arti- 
ficial   Respiration.^  —  Meltzer 

has  evolved  two  methods  for  the  induction  of  artificial  respiration : 
Pharyngeal  tube;   (2)   mask,  as  in  other  devices.     In  either  case 
>  J.  Am.  Med.  Assn.,  May  10,  1913,  1407. 


Fig.  144. — The  Lungmotor. 


(1) 
the 


Fig.  145. — Meltzer's  Apparatus  for  Artificial  Respiration  with  Pharyngeal 
Tube  and  Foot  Bellows.  P.  T.,  pharyngeal  tube;  R.  V.,  respiratory  valve.  The 
ling  turns  the  valve;  turning  to  the  right  (facing  the  pharyngeal  tube)  brings  an  in- 
spiration and  to  the  left  brings  an  expiration.  B.,  foot-bellows;  S.  V.,  safety-valve. 
The  bottle  of  the  safety-valve  should  be  shorter  and  have  a  wider  diameter  than  the 
one  in  the  figure;  it  is  less  likely  to  turn  over.  S.  T.,  stomach-tube  introduced  through 
the  opening  in  the  pharyngeal  tube. 


Fig.  146. — ^Meltzer's  Apparatus  foe  Artificial  Respiration  with  Mask  Attached 
to  Oxygen  Tank.  M.,  mask;  Infl.,  tube  for  inflating  the  rubber  ring  around  the 
rim  of  the  mask;  R.  V.,  respiratory  valve;  S.  V.,  safety-valve.  An  oxygen  cylinder 
provides  here  the  insufflation  pressure.  The  figure  shows  also  the  weight  on  the  abdo- 
men and  the  belt  around  it. 


TREATMENT  BEFORE,  DURING,  AND  AFTER  ANESTHESIA     401 

apparatus  is  operated  by  means  of  foot  bellows,  compressed  air  or  oxygen 
from  a  tank,  or  a  motor.  Figs.  145  and  146  illustrate  clearly  the 
mechanism  and  application  of  these  devices. 

Meltzer  demonstrated  that  the  blood  pressure  is  considerably  raised 
by  placing  weights  upon  the  abdomen,  thus  greatly  increasing  the  proba- 
bility of  a  successful  termination  of  the  efforts  at  resuscitation. 

"The  weight  of  the  abdomen  prevents  the  entrance  of  air  in  any  con- 
siderable quantity  into  the  stomach,  and  the  little  which  gets  there  es- 
capes again  when  the  insufflation  is  cut  off;  it  never  gets  into  the  intes- 


FiG.  147. — Blood-Pressure  Tracing  from  an  Etherized  Dog  Which  Received  an 
Intravenous  Injection  of  Sodium  Nitrite.  Blood-pressure  low,  44  millimeters; 
pressure  on  the  abdomen  brings  up  the  blood  pressure  to  70  millimeters  mercury,  and 
the  pulse  pressure  is  nearly  doubled  in  size. 

tines.  The  pressure  on  the  abdomen  has  still  another  significance.  In 
patients  with  completely  abolished  respiration  usually  the  blood  pressure 
is  also  very  low,  and  most  of  the  blood  may  be  accumulated  in  the  ab- 
dominal viscera.  The  heart  is  then  scantily  filled,  and  not  enough  ar- 
terial blood  is  sent  to  peripheral  organs.  Under  such  circumstances  a 
good  pressure  on  the  abdomen  may  raise  the  blood  pressure  by  even  as 
much  as  30  millimeters  of  mercury;  the  heart  is  filled  more  efficiently, 
and  sends  more  blood  to  the  medulla  oblongata,  arousing  there  the  activi- 
ties of  the  respiratory  and  vasomotor  centers." 

Figure  147  shows  the  effect  of  abdominal  pressure  on  the  blood 
pressure. 

Theories  Concerning  the  Cause  of  Shock. — The  theories  concerning 
the  cause  of  shock,  however  produced,  whether  by  the  anesthetic  or  by 
the  surgical  procedure,  have  come  to  be  accepted  as  falling  under  two 
heads : 

(1)  Crile's  theory  of  deoxygenation,  or  paralysis  of  the  vasomotor 
centers,  with  a  "manifest  transference  of  the  blood  from  the  arteries 
into  the  veins." 

(2)  Henderson's  acapnia  theory,  or  the  hyperactivity  of  the  vaso- 


402  ANESTHESIA 

motor  centers  through  loss  of  carbon  dioxid  from  the  tissues  and  the  cir- 
culating blood. 

Vasomotor  Paralysis  (Deoxygenation) — Crile. — The  phe- 
nomena of  shock,  according  to  this  theory,  are  due  to  the  exhaustion  of 
the  vasomotor  centers  in  the  medulla  and  spinal  cord,  with  the  resultant 
loss  of  control  of  the  pressure  of  the  blood  in  the  arterial  system  and 
the  consequent  collection  of  the  blood  in  the  great  splanchnic  reservoir 
in  the  abdomen.  The  fall  in  blood  pressure  which  follows  this  loss  of 
control  is  accompanied  by  a  fall  in  the  general  body  temperature;  the 
respirations  become  weak  from  secondary  exhaustion  of  the  respiratory 
centers,  the  blood  and  tissues  are  not  properly  oxygenated,  and  the  oxy- 
gen starvation  described  heretofore  (see  p.  97),  if  not  checked,  leads  to 
loss  of  consciousness  and  eventual  paralysis  of  all  vital  functions  and 
death. 

This  theory  of  shock  is  accepted  by  Mummery,  Latham,  and  English, 
and  a  number  of  others. 

Prevention  of  Shock  {Crile). — Prevent  as  far  as  possible  the  loss  of 
blood.  Atropin,  hypodermically  administered,  was  an  efficient  protec- 
tion against  cardiac  inhibition  in  operations  in  the  "inhibition  area"  in 
the  larynx,  and  in  such  operations  as  might  cause  mechanical  stimula- 
tion of  the  vagi.  Cocain,  hypodermically  injected,  guards  the  heart 
against  cardiac  inhibition  almost  as  efficiently  as  does  atropin.  "For 
morphin  and  alcohol,  our  observations  were  negative."  Tearing,  manip- 
ulating, stretching,  forced  dissection,  all  tend  to  produce  shock,  more 
than  the  use  of  sharp  instruments  and  gentle  manipulation. 

"Animals  to  which,  while  inducing  anesthesia,  an  overdose  had  been 
given  did  not  endure  a  prolonged  experiment,  and  not  only  was  it  more 
difficult  to  maintain  an  even  anesthesia  afterward,  but  the  animal  also 
showed  a  marked  tendency  to  recurring  respiratory  failures." 

So  far  as  could  be  judged,  less  shock  was  produced  when  warm  so- 
lutions were  used  than  when  cold;  when  the  laboratory  was  warm,  than 
when  near  the  freezing  point. 

Moist  heat  ^  protecting  the  tissues  lessened  the  amount  of  local  irri- 
tation, and  hence  the  shock. 

Posture. — Posture  is  of  considerable  importance.  The  blood  pressure 
always  rose  when  the  head  was  tilted  dowuAvard,  and  fell  when  the  board 
was  tilted  in  the  opposite  direction. 

Operations  upon  the  extremities,  if  performed  bloodlessly,  and  if  the 
nerve  trunks  had  been  subjected  to  a  cocain  "block,"  produced  no  shock. 
Amputation  of  a  leg  caused  no  more  effect  than  did  cutting  the  hair.  In 
rough  axillary  and  chest  dissections  there  was  a  marked  tendency  to 
respiratory  failure.     In  abdominal  procedure,  if  the  omentum  was  made 

^  See  Chapter  on  General  Physiology  (Warming  the  Anesthetic;  The  Utili- 
zation of  Moisture). 


TREATMENT  BEFORE,  DURING,  AND  AFTER  ANESTHESIA     403 

to  cover  the  viscera,  thereby  preventing  direct  contact  with  them,  there 
was  very  much  less  shock.  Handling  the  omentum  did  not  produce 
vasomotor  and  respiratory  disturbance.  Dragging  in  the  mesentery  was 
followed  by  a  decline  in  blood  pressure.  In  operations  upon  the  gall- 
bladder and  liver  it  was  necessary  to  be  cautious  as  to  traction  on  account 
of  the  great  fluctuation  in  blood  pressure  likely  to  be  caused  by  mechani- 
cal interference  with  the  larger  venous  trunks.  The  most  dangerous  area 
is  in  the  region  of  the  duodenum,  pylorus,  and  gall-bladder.  The  least 
dangerous  area  is  the  pelvic  peritoneum  and  its  viscera.  The  uterus, 
tubes,  and  ovaries  contribute  but  little  to  shock,  even  when  they  are  se- 
verely crushed  and  torn.  The  severity  of  shock  induced  in  abdominal 
operations  is  in  direct  ratio  to  the  distance  from  the  pelvis.  Injuries  of 
the  large  intestines  produce  much  less  depression  of  the  blood  pressure 
than  those  of  the  small  intestines;  injuries  of  the  stomach  about  the  same 
as  the  small  intestines. 

Intravenous  infusion  of  normal  saline  solution  causes  all  the  blood 
pressures  to  rise.  Quantities  up  to  twice  the  amount  of  blood  calculated 
to  be  in  the  animal  have  been  given  before  the  pressure  was  sustained. 
The  value  of  these  injections  is  apparently  wholly  mechanical.  The 
combination  of  small  and  frequently  repeated  hypodermic  injections  of 
strychnin,  together  with  saline  infusion,  produces  a  sustained  effect. 
Overstimulation  was  followed  later  by  a  greater  depression.  The  appli- 
cation of  heat  was  of  benefit. 

Treatment  of  Shock  in  Accordance  with  the  Vasomotor  Paralysis  or 
Deoxygenation  Theory. — Naturally,  if  one  accepts  the  theory  of  shock 
proposed  by  Crile,  the  treatment  must  be  carried  out  accordingly.  Crile 
recommends  the  use  of  strychnin  sulphate  and  artificial  respiration;  in 
other  words,  an  increase  in  the  supply  of  oxygen. 

Latham  and  English  ^  advocate  the  following  measures :  "The  prin- 
cipal factor  in  treating  shock  is  to  maintain  an  efficient  circulation  until 
such  time  as  the  vasomotor  centers  have  recovered,  and  at  the  same  time 
to  secure  rest  to  the  brain  during  that  period.  The  use  of  stimulants  is 
therefore  contraindicated,  especially  strychnin.  Inject  morphin  and 
raise  the  foot  of  the  bed  three  feet  so  as  to  place  the  abdomen  on  a  higher 
level  than  the  head  and  thorax  (chairs  are  better  than  blocks  for  this 
purpose),  this  position  to  be  maintained  until  all  symptoms  of  shock 
have  worn  off.  Bandaging  the  abdomen  tightly  assists  in  raising  the 
blood  pressure.  This  bandage  must  not  embarrass  the  movements  of  the 
chest;  for  the  same  reason  heavy  bedclothes  must  be  supported  on  a 
cradle.    Bandaging  the  extremities  is  also  useful  in  some  cases. 

"Increasing  the  total  quantity  of  fluid  in  the  circulation  by  infusion 
of  normal  saline  tends  to  raise  the  blood  pressure,  and  aids  in  recovery 
of  vasomotor  centers.  Adrenin  in  suitable  quantities  added  to  the 
^  Latham  and  Crisp  English :     "A  System  of   Treatment, ' '  93. 


404  ANESTHESIA 

saline  materially  assists.  Adrenin,  they  hold,  acts  directly  upon  the 
peripheral  arteries,  and  causes  a  great  increase  in  the  blood  pressure 
without  acting  upon  the  nerve  centers.  Its  action  is  transitory,  and  it 
must  be  put  directly  into  the  vein.  It  should  only  be  added  to  solutions 
which  are  introduced  directly  into  the  veins.  It  is  useless  to  add  to 
solutions  which  are  introduced  per  rectum  or  subcutaneously.  Eectal 
infusion  is  useful  in  cases  of  slight  or  early  shock  (or  to  prevent  shock), 
as  is  also  subcutaneous  infusion." 

Intravenous  Infusion  in  Serious  Cases  of  Shock. — Infusion,  to  be 
effective,  must  be  carried  out  continuously  until  the  patient  is  well  on  the 
way  to  recovery  and  is  out  of  danger. 

Transfusion  of  human  blood  is  far  more  effective  than  any  form  of 
saline  infusion. 

Pituitary  Extract. — This  is  similar  in  action  to  adrenin,  although 
as  used  at  present  the  drug  is  not  so  powerful.  It  has  the  advantage 
over  adrenin  that  its  effects  last  from  a  half  hour  to  one  hour.  It  must 
also  be  injected  into  a  vein.  It  can  be  administered  in  fairly  large 
doses  with  safety,  but  subsequent  doses  have  less  effect  than  the  original 
dose. 

Keen  ^  recommends  the  following  measures :  "  ( 1 )  The  prevention  of 
further  shock;  (2)  the  support  of  the  circulation;  (3)  the  securing  of 
physiologic  rest." 

Support  of  the  Circulation. — Head-down  posture  increases  blood  in 
brain,  heart,  and  lungs.  Extremities  and  abdomen  may  be  bandaged. 
Use  heavy  layers  of  cotton  and  broad  flannel  bandages.  Crile's  pneu- 
matic rubber  suit  is  the  best,  as  the  pressure  is  under  control,  and  the 
air  placed  in  the  suit  may  be  warmed  and  the  pressure  increased  or 
diminished  without  disturbing  the  patient.  The  blood  pressure  may  be 
raised  in  this  way  frorii  15  to  40  mm.  mercury.  Saline  infusions  may  be 
given. 

Physiologic  rest  is  the  most  important  consideration  in  the  treatment 
of  shock.  "When  the  motor  activity  takes  the  form  of  obvious  work  per- 
formed, such  as  running,  the  depletion  of  the  vital  force,  expressed  by 
various  phenomena,  is  termed  physical  exhaustion.  When  the  expendi- 
ture of  the  vital  force  is  due  to  stimuli  which  lead  to  no  obvious  work 
performed,  especially  if  the  stimuli  are  strong  and  the  expenditure  of 
energy  rapid,  it  is  designated  as  shoclc." 

Under  nitrous  oxid  anesthesia  the  physiologic  changes  and  the  brain 
cell  changes,  following  an  equal  trauma,  were  approximately  one-third 
those  following  ether. 

Traumatized  animals  whose  blood  pressures  were  maintained  by  di- 
rect transfusion  of  blood,  thereby  eliminating  the  factor  of  anemia,  still 
showed  physical  changes  in  their  brain  cells;  animals  similarly  anes- 

^Loc.  cit. 


TREATMENT  BEFORE,  DURING,  AND  AFTER  ANESTHESIA     405 

thetized    and    transfused,    but    not    traumatized,    showed    no    change. 
"Shock  is  an  overstimulation  of  the  whole  motor  mechanism." 

Anoci-association. — "If  the  patient  be  kept  free  from  any  emotional 
excitations  by  special  management  and  by  narcotics,  or  be  not  permit- 
ted to  know  that  the  operation  is  to  be  performed  at  a  special  time, 
and  if  such  patient  be  anesthetized  in  such  a  manner  that  no  adap- 


Degreejs, 

98 

99 

100 

101 

\01 

103 

Ethsr. 

< 

NaO. 

1^ 
W 

H 

Anoci. 

Be&X?. 

70 

80 

90 

100 

110 

120 

Ether. 

NaO. 

Ph 

Anoci. 

Fig.  148. — Chile's  Abdominal  Hystehectomy  Chart.  Temperature:  each  heavy  line 
represents  the  average  5:00  P.  M.  temperature  of  ten  patients  during  the  first  four 
days  after  operation.  Pulse:  each  heavy  line  represents  the  average  5:00  P.  M.  pulse 
rate  of  ten  patients  during  the  first  four  days  after  operation. 

tive  response  is  excited  by  such  an  anesthetic  as  the  pleasant  nitrous 
oxid,  and  if  the  field  of  operation  be  so  completely  blocked  by  local  anes- 
thesia that  no  traumatic  impulse  reaches,  the  brain,  and  if  in  closing 
the  wound  another  local  anesthetic  is  employed  that  will  block  nerve  imi- 
pulses  for,  say,  twenty-four  hours,  thus  preventing  the  after-pains,  such  a 
patient  will  then  have  been  operated  upon  in  such  a  manner  that  the 
motor  mechanism  has  received  no  adequate  stimulus."  Hence  there  is  no 
surgical  shock,  nor  interference  with  digestion,  nor  nervous  impairment 
afterward,  i.  e.,  no  change  in  the  circulation,  the  respiration,  the  digestive 
functions,  nor  the  mentality  of  the  patient. 

"Although  ether  anesthesia  produces  unconsciousness  it  apparently 
protects  none  of  the  brain  cells  against  exhaustion  from  the  trauma  of 
surgical  operations." 

Under  nitrous  oxid  anesthesia  there  is  approximately  only  one- 
fourth  as  much  exhaustion,  after  equal  trauma,  as  under  ether.  "Either 
nitrous  oxid  protects  or  ether  predisposes  to  exhaustion  under  trauma." 

Causes  and  Prevention  of  Post-operative  Gas  Pains. — "The 
patient  is  anesthetized  as  usual,  but  the  entire  line  of  incisions  is  care- 


406 


ANESTHESIA 


fully  blocked  with  novocain,  including  the  peritoneum.     If  then,  at  the 
end  of  the  operation  and  before  the  peritoneum  is  closed,  there  is  applied 


Degree3 

98 

99 

100 

\0\ 

102 

103 

Et^er. 

H 

W 

NzO. 

W 
H 

Anoci. 

Beaut>s. 

70 

80 

90 

100 

no 

120 

Ether. 

Na.0. 

Anoci. 

Fig.  149. — Chile's  Thyroidectomy  Chart.  Temperature:  each  heavy  line  represei.ts 
the  average  5:00  P.  M.  temperature  of  ten  patients  during  the  first  four  days  after 
operation.  Pulse:  each  heavy  line  represents  the  average  5:00  P.  M.  pulse  rate  of  ten 
patients  during  the  first  four  days  after  operation. 

around  the  entire  line  of  stitches  a  complete  anesthetic  block  that  will 
last  a  number  of  days  (as  50  per  cent  alcohol  or  quinin  and  urea  hydro- 
chlorid),  and  if  in  stitching  the  peritoneum  every  stitch  is  placed  within 
this  blocked  zone,  then  the  afferent  impulses  caused  by  stitch  irritation 
are  blocked,  and  hence  cannot  excite  the  protective  mechanism  of  intes- 


death  rate. 

%              / 

2 

3 

^ 

5 

6 

T 

p^r   -ooo 

1908 

Cast  loooCtS 

s 

Fig. 


150. — Crile's  Chart  of  Mortality  Rate  per  Thousand  of  Operative  Cases 
FROM  Lakeside  Hospital.     The  last  thousand  were  under  anoci. 


final  inhibition.  It  has  been  found  that  such  blocking  does  minimize  or 
even  prevent  post-operative  gas  pains  in  all  sorts  of  abdominal  opera- 
tions.'^ 

Vasomotor  Hyperactivity  (Acapnia) — Henderson. — The  chief 
opponent  of  the  vasomotor  paralysis  or  deoxygenation  theory  of  shock 
is  Yandell  Henderson,  the  originator  of  the  theory  that  shock  is  due  to 
the  hyperactivity  of  the  vasomotor  centers,  as  a  consequence  of  the  loss, 


TREATMENT  BEFORE,  DURING,  AND  AFTER  ANESTHESIA     407 

for  some  reason,  of  carbon  dioxid,  and  the  effort  on  the  part  of  the  organ- 
ism to  compensate  for  this  loss. 

We  cannot,  perhaps,  better  explain  Henderson's  theory  than  by  quot- 
ing from  one  of  his  papers  ^  an  illustrative  case : 

"A  man  in  the  prime  of  life  was  setting  off  fireworks  when  a  giant 


A.  B.  C.  D. 

Fig.  151. — Operations  Under  Anoci-association.      A.  Appendectomy.     B.  Herniot- 
omy.    C.  Hysterectomy.     D.  Cholecystotomy.     (Crile.) 

firecracker  exploded  in  his  hand  and  shattered  it.  There  was  no  con- 
siderable loss  of  blood.  For  two  hours  he  suffered  intensely,  although 
he  received  a  quarter  of  a  grain  of  morphin.  Then  anesthesia  with 
ether  was  attempted,  and  his  breathing  immediately  began  to  fail.  The 
anesthetic  was  withdrawn,  and  respiration  improved.  Three  hours  after 
the  accident  he  stopped  breathing  quite  suddenly.  Artificial  respiration 
and  stimulants  were  ineffective,  and  he  died.     Yet  his  pulse  was  fairly 


A.  B.  C. 

Fig.  152. — Technique  of  Abdominal  Operation  Under  Anoci-association.  A.  Infil- 
tration of  skin  and  subcutaneous  tissue  with  1-400  novocain.  B.  Infiltration  of  fascia 
and  muscle.  C.  Infiltration  of  posterior  sheath  and  peritoneum.  D.  Peritoneum 
inverted;  infiltration  with  H  per  cent,  of  quinin  and  urea  hydrochlorid.     (Crile.) 

good  before  and  even  for  some  minutes  after  respiration  ceased.  Why 
did  that  man  die?  In  order  to  make  the  further  discussion  of  my  topic 
clear,  I  will  present  immediately  the  explanation  to  which,  as  it  seems 
to  me,  all  the  data  point.  During  the  period  after  the  accident  his 
breathing  was  of  the  type  which  insupportable  pain  always  excites.  This 
hyperpnea  involved  a  far  greater  ventilation  of  the  lungs  than  normal 
breathing  affords.  Consequently  the  CO2  content  of  the  blood,  and 
finally  also  of  the  body  as  a  whole,  was  greatly  diminished.     When  the 

^Henderson,  Tandell:     "Fatal  Apnea  and  the  Shock  Problem,"  Johns  Hop- 
kins Eosp.  Bull,  Aug.,   1910,  SI,  No.  233. 


408  ANESTHESIA 

anesthesia  was  attempted  it  was  almost  inevitable  that  respiration  should 
show  signs  of  failure.  CO2  is  the  normal  stimulant  of  respiration;  there- 
fore, after  this  normal  chemical  stimulant  to  breathing  had  been  re- 
duced, pain  alone  maintained  the  breathing.  Anesthesia  removed  the 
pain.  Finally  breathing  stopped  for  the  very  simple  reason  that  there 
was  not  enough  CO,  left  in  the  blood  to  excite  the  respiratory  center  to 
activity.  To  this  condition  of  diminished  CO2  content  in  the  blood 
Mosso  has  given  the  name  "acapnia,"  from  the  Greek  "kapnos,"  smoke. 
Literally,  acapnia  means  smokelessness.  Perhaps  I  should  remind  you 
that  the  arterial  l)lood  normally  contains  20  volumes  per  cent  of  oxygen, 
and  40  of  CO,,  and  that  the  body  as  a  whole  has  an  enormously  greater 
store  of  CO2  than  of  oxygen." 

Henderson  instituted  a  long  series  of  experiments  Avhich  are  now 
too  well  known  to  need  repetition  here.  His  observations  led  him  to  the 
conclusion  that  the  condition  of  low  arterial  pressure,  noted  in  shock, 
is  not  due  to  fatigue  or  inhibition  or  failure  of  any  sort  in  the  vaso- 
motor center.  On  the  contrary,  in  his  opinion,  this  center  does  its  full 
duty  almost  to  the  last.  The  failure  of  circulation  appears,  in  his  ex- 
perience, to  be  due  to  diminution  in  the  volume  of  the  blood  by  transu- 
dation of  its  fluids  out  of  the  vessels  into  the  tissues,  a  process  resem- 
bling edema.  "It  is  a  complex  peripheral  process,"  he  says,  "induced 
initially  by  the  influence  of  acapnia  upon  the  veins  and  capillaries  and 
upon  the  tissues.  Thus  when  death  (or  shock)  follows  intense  physical 
suffering,  not  complicated  by  hemorrhage,  there  are  two  principal  stages. 
At  first  the  excessive  breathing  diminishes  the  CO,  content  of  the  blood. 
If,  at  any  time  after  this  condition  of  acapnia  has  been  induced,  the  pain 
is  greatly  diminished,  and  the  respiratory  center  is  thus  allowed  to  re- 
lapse into  standstill,  fatal  apnea  vera  may  occur.  If,  on  the  other  hand, 
the  pain  is  sufficiently  continuous  to  keep  the  respiratory  center  con- 
tinually excited,  then  apnea  is  prevented,  and  the  condition  of  acapnia 
becomes  more  and  more  acute  and  general  until  the  circulation  fails, 
and  the  subject  sinks  into  surgical  shock."  Both  fatal  apnea  and  the 
more  slowly  developing  failure  of  circulation,  he  holds,  are  due  ini- 
tially to  acapnia  induced  by  the  excessive  breathing  occurring  under 
torture. 

He  does  not  agree  to  the  importance  of  the  role  ascribed  by  others  to 
oxygen  in  maintenance  of  the  function  of  the  respiratory  center.  On  the 
contrary,  he  considers  that  Mischer  expressed  the  essential  truth  regard- 
ing the  regulation  of  normal  breathing :  "Over  the  oxygen  supply  of  the 
blood  CO,  spreads  its  protecting  wings." 

Henderson  considers  that  death  from  respiratory  failure  is  explained 
as  due  to  these  "protecting  wings." 

"Those  cases  of  fatal  apnea,"  according  to  Henderson,  "which  more 
than  any  other  interest  the  clinician,  are,   I   suppose,   the  failures  of 


TREATMENT  BEFORE,  DURING,  AND  AFTER  ANESTHESIA     409 

respiration  under  anesthesia.  If  the  patient  ceases  to  breathe  in  his 
bed,  it  is  his  own  fault,  but  if  he  does  so  on  the  operating  table  the 
anesthetist  has  to  bear  the  responsibility.  For  such  cases  of  apnea 
the  acapnia  hypothesis  affords  a  simple  explnnation.  Anesthesia  di- 
minishes the  strength  of  inflowing  afferent  irritations.  Furthermore 
profound  anesthesia  raises  the  threshold  of  the  respiratory  center  for 
CO2.  In  other  words,  the  respiratory  center  of  a  man  or  animal  in  pro- 
found anesthesia  automatically  maintains  more  than  the  normal  COo 
content  in  the  blood.  Thus,  when  a  man  or  a  woman  or  a  child  has  suf- 
fered prolonged  pain,  and  thereby  has  been  brought  into  a  condition  of 
more  or  less  acapnia,  the  production  of  anesthesia  by  removing  the  affer- 
ent pain  stimuli,  and  also  by  raising  the  threshold,  that  is,  by  dimin- 
ishing the  sensitiveness,  of  the  respiratory  center  for  CO,,  inevitably 
leads  to  apnea." 

Prevention  of  Acapnia. — The  prevention  of  acapnia  calls  for  the 
prevention  of  excessive  pulmonary  ventilation.  According  to  Hender- 
son, the  administration  of  morphin  and  full  anesthesia  diminishes  the 
activity  of  respiration  under  pain,  and  thus  prevents  acapnia.  If,  how- 
ever, morphin  and  chloroform  be  administered  to  an  animal  which  has 
suffered  pain  for  some  time,  apnea  is  hastened  unless  carbon  dioxid  is 
also  administered. 

In  moderate  degrees  of  shock,  induced  by  irritation  of  afferent 
nerves  or  by  exposure  of  the  viscera,  Henderson  has  found  it  possible 
to  induce  rapid  recovery  by  the  infusion  into  a  vein  of  normal  saline  or 
Einger's  solution  saturated  with  carbon  dioxid,  and  then  making  the  sub- 
ject breathe  an  atmosphere  of  oxygen  and  carbon  dioxid  or  oxygen  alone. 

In  profound  shock  he  has  found  that  these  measures  fail  to  effect  an 
ultimate  recovery. 

Treatment. — Henderson  outlines  two  methods  of  treating  acapneal 
respiration  under  anesthesia.  One  method  involves  the  intratracheal 
insufflation  of  a  gentle  stream  of  oxygen  gas,  according  to  the  method 
devised  by  Volhard.  For  man  the  quantity  of  oxygen  should  be  not  less 
than  400  c.  c.  per  minute. 

The  other  method  of  restoration  of  breathing  to  which  Henderson 
refers  has  been  found  by  him  to  be  remarkably  successful  in  restoring 
dogs  during  apnea.  It  consists  in  the  administration  of  air  or  oxygen 
containing  5  or  6  per  cent  of  carbon  dioxid,  the  breathing  being  started 
by  one  or  two  artificial  respirations.  As  soon  as  the  normal  tension  of 
carbon  dioxid  in  the  lungs  is  restored,  spontaneous  breathing  imme- 
diately recommences  and  continues  as  long  as  the  inspired  air  contains 
a  sufficient  quantity  of  carbon  dioxid  to  stimulate  the  respiratory  center. 

McKeson  for  the  past  five  years  has  used  an  apparatus  for  measuring 
the  blood  pressure  in  connection  with  all  anesthetics,  for  the  special  pur- 
pose of  anticipating  shock.    His  remarks  follow : 


410  ANESTHESIA 


THE  INTERPRETATION  OF  PULSE,  RESPIRATION,   AND  BLOOD 

PRESSURES  WITH  SPECIAL  REFERENCE  TO 

SURGICAL  SHOCK 

"What  is  the  purpose  of  taking  blood  pressures  during  opera- 
tions ? 

"  'Feeling  the  pulse'  has  proved  to  be  an  unreliable  method  in  de- 
termining the  pressure  values  of  the  pulse.  And,  if  the  anesthetist  is 
to  be  acquainted  with  the  condition  of  his  patient,  he  must  be  able  to 
determine  quite  accurately  these  pressures  for  comparison  as  the  opera- 
tion proceeds.  To  anticipate  shock  and  to  apply  remedial  measures  be- 
fore the  process  has  become  well  advanced  requires  an  earlier  recogni- 
tion than  is  possible  without  the  sphygmomanometer. 

"Before  shock  (excluding  shock  from  hemorrhage)  becomes  so  well 
established  that  it  may  be  positively  diagnosed  clinically,  the  patient 
passes  through  certain  circulatory  disturbances  which  are  indicative  of 
the  condition  to  follow  as  certainly  as  certain  weather  conditions  fore- 
cast rain. 

"What  are  the  important  factors  in  making  this  interpretation  ? 

"Let  us  first  state  briefly  a  few  facts  concerning  the  physiology  in- 
volved in  the  maintenance  of  blood  pressure.  The  heart  is  the  pump; 
the  great  arteries  are  more  or  less  elastic  and  admit  more  blood  from 
the  heart  by  distention;  the  arterioles  are  the  'shut-off'  valves  control- 
ling peripheral  resistance  and  determining  the  volume  of  blood  to  pass 
through  a  certain  group  of  capillaries;  the  capillaries  and  veins  act  in 
this  connection  as  return  tubes  to  the  heart  and  lungs,  which  return  the 
blood  through  the  pressure  of  various  muscles,  gravity,  and  suction  by 
the  heart  and  lungs. 

"The  pressure  in  the  arteries  before  systole  represents  the  conditions 
of  resistance  and  elasticity  of  the  vessels.  Other  things  being  equal,  an 
increase  in  the  diastolic  pressure  means  more  resistance;  a  decrease,  less 
resistance  in  the  arterioles.  At  the  next  ventricular  contraction  the  heart 
must  produce  enough  pressure  to  equal  the  diastolic  pressure  before  the 
valves  will  open;  from  this  point  the  remaining  portion  of  the  contrac- 
tion will  produce  the  discharge  of  blood  into  the  aorta,  and  is  called 
pulse  pressure — the  discharge  power  of  the  heart. 

"The  pulse  pressure  is  the  working  pressure  in  moving  the  blood, 
and  concerns  the  heart  only.  So  that  it  represents  the  most  important 
single  guide  to  the  power  of  the  heart. 

"The  systolic  pressure  represents  the  pressure  developed  during  sys- 
tole, and  is  the  sum  of  the  diastolic  and  pulse  pressures.  It  is  evident 
that  the  systolic  pressure  will  be  more  variable  than  the  diastolic,  for  it 
must  accommodate  itself  to  variations  in  the  heart  rate  and  pulse  pres- 


TREATMENT  BEFORE,  DURING,  AND  AFTER  ANESTHESIA     411 

sures,  and  is  therefore  not  as  valuable  a  sign  as  was  formerly  supposed 
in  determining  oncoming  shock. 

"The  heart  must  maintain  a  certain  pressure  in  the  aorta  that  its 
own  tissues  may  be  properly  bathed  in  blood  through  the  coronaries. 
This  may  be  accomplished  in  falling  pressures  by  increasing  the  output 
of  the  heart  and,  to  some  extent,  by  increased  peripheral  resistance, 
althoiigh,  clinically,  after  arterioles  once  dilate,  the  heart  must  usually 
compensate  by  increasing  its  output,  as  they  seldom  regain  their  tone 
during  operation. 

"Eespiration  aids  the  heart  in  producing  blood  pressure  in  tin;  lui- 


FiG.   153. — Blood  Pressurs  Apparatus  as  Used  by  McKeson. 

man  subject.  Intrapulmonary  pressure  is  increased  during  exhalation, 
aiding  the  heart  to  force  the  blood  out  of  the  chest.  This  force  under 
anesthesia  normally  increases  the  blood  pressure  from  5  to  10  mm.  of 
mercury  above  the  reading  obtained  during  inhalation.  During  inhala- 
tion the  blood  is  drawn  out  of  the  great  veins  leading  into  the  thorax, 
so  readily  seen  during  extensive  neck  or  breast  operations;  at  the  same 
time  the  capillary  resistance  in  the  lungs  is  greatly  reduced,  so  the  right 
heart  can  more  easily  force  a  large  volume  of  blood  over  to  the  left  side. 
And  when  exhalation  begins  again  the  lungs  squeeze  out  the  excess  blood 
into  the  left  heart,  increase  intrapiilmonary  pressure,  and  again  blood 
pressure  is  elevated. 

"It  should  be  remembered  that  with  the  abdomen  open  the  diaphragm 
cannot  increase  intra-abdominal  pressure,  and  the  return  of  blood  from 
the  abdomen  at  the  time  of  chest  aspiration  (inhalation)  will  not  be  as 
perfect  as  usual,  which  may  be  an  important  element  in  venous  stasis 
here. 


412 


ANESTHESIA 


"A  respiratory  rate  of  more  than  30  per  minute  is  too  rapid  to  assist 
in  moving  the  blood,  throv/ing  the  whole  burden  on  the  heart.  Also,  a 
constant  intrapulmonary  pressure  interferes  with  venous  supply  to  the 
heart. 

"An  obstructed  airway  of  any  considerable  degree,  on  the  other  hand, 
increases  the  respiratory  variation  of  blood  pressure,  but  if  the  respira- 
tions are  too  long  and  powerful  it  has  the  same  effect  as  a  continued 
positive  pressure — interfering  with  the  venous  return  and  increasing 
the  danger  of  a  dilated  right  heart. 


REMARKS 

OXYGEN   BEBRCATHINO 

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present  condition 

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Fig.  154. — McKesoh's  Blood  Pressure  Chart  No.  3908. 


"In  order  to  clarify  our  previous  statements  and  to  apply  them  to  a 
concrete  case,  let  us  examine  a  copy  of  our  chart  ISTo.  3908;  a  woman 
aged  64,  weight  120,  in  good  physical  condition,  was  operated  on  for  ob- 
struction of  the  colon  with  adhesions,  and  the  appendix  was  removed. 
An  H.  M.  C.  tablet  containing  1/6  grain  morphin  was  given  hypodermi- 
cally  about  1  hour  before.  The  anesthetic  was  ^,0  and  0^  without  novo- 
cain infiltration  in  the  line  of  the  incision.  Just  before  anesthetization, 
the  (S)  systolic  pressure  was  135,  the  (D)  diastolic  pressure  90,  making 
a  pulse  pressure  of  45,  pulse  82,  respiration  20. 

"During  the  first  15  minutes  of  the  anesthesia  nothing  happened  ex- 
cept a  very  slight  increase  in  respiration  frequency.  During  the  latter 
portion  of  this  time  abdominal  manipulations  and  traction  on  the  intes- 
tines was  followed  by  a  slight  fall  at  (A)  in  the  pulse  rate,  a  25  mm. 
fall  of  systolic,  and  a  10  mm.  fall  of  the  diastolic  pressures.  In  the  be- 
ginning we  had  a  pulse  pressure  of  45  mm.,  which  was  probably  nearly 
normal  for  this  patient,  while  at  the  end  of  25  minutes  it  was  35  mm. 
What  had  happened? 

"When  the  intestines  were  exposed,  handled,  and  dragged  up,  and 
rough  gauze  pads  introduced  into  the  belly  to  paclc  certain  loops  away 


TREATMENT  BEFORE,  DURING,  AND  AFTER  ANESTHESIA     413 

from  the  desired  field,  the  arterioles  relaxed  and  the  diastolic  pressure 
fell.  With  an  easier  outlet  for  the  blood  and  a  comparatively  slow  pulse, 
the  pulse  pressure  weakened  slightly  and  the  systolic  fell  markedly. 

"This  is  not  shock,  but  if  it  should  continue  as  started  it  would  re- 
sult in  shock  in  about  30  minutes  or  when  the  pulse  pressure  is  but  10 
to  15  mm.  and  the  diastolic  is  70  mm.  or  less.  There  was  no  reason  for 
apprehension  in  this  case,  for,  between  (B)  and  (C),  when  less  trauma 
was  inflicted  while  doing  the  appendectomy,  there  was  a  compensatory 
increase  of  the  heart  rate,  bringing  the  pressures  to  their  former  posi- 
tions. Of  course,  this  cost  the  heart  25  beats  more  each  minute,  but  the 
reserve  power  in  a  heart  not  already  complicated  with  disease  is  usually 
sufficient  to  keep  up  a  rapid  rate  for  several  hours,  provided  that  pres- 
sure is  maintained.  It  shows  here  that  the  arterioles  are  still  open,  and 
even  in  the  last  10  minutes,  when  more  0  is  used  in  the  mixture,  as 
the  pulse  falls  the  diastolic  falls;  but  10  minutes  after  the  anesthesia 
and  operation  are  completed  the  pulse,  respiration,  and  blood  pressure  re- 
lations are  practically  reestablished  as  before  the  anesthesia  was  begun. 

"So  it  is  possible  by  an  intelligent  interpretation  of  the  pulse,  respira- 
tion, and  blood  pressure  to  anticipate  the  occurrence  of  surgical  shock 
at  least  20  minutes  and  usually  much  longer. 

"Anesthetic  overdosage,  however,  must  not  be  confused  with  surgical 
shock,  although  many  of  the  signs  are  similar  in  the  relative  overdosage 
cases,  and  the  respiration  and  heart  may  be  brought  to  a  standstill  in  a 
very  few  minutes." 

Post-Anesthetic  Toxemia 

The  second  of  the  major  difficulties  which  may  arise  as  a  conse- 
quence of  the  administration  of  an  inhalation  anesthetic  is  post-anes- 
thetic toxemia.  Acetonuria,  acetonemia,  acidosis,  acid  intoxication  are 
terms  applied  to  delayed  chloroform  poisoning,  concerning  which  a 
voluminous  literature  has  been  compiled  within  recent  years.  Ether 
also  is  now  believed  to  give  rise  to  acid  intoxication. 

It  is  the  opinion  of  some  observers,  the  senior  author  among  this 
number,  that  so-called  post-anesthetic  toxemia  exists  only  in  cases  in 
which  there  is  already  a  tendency  to  acidosis,  or  in  which  this  condi- 
tion is  precipitated  by  careless  technique  on  the  part  of  the  anesthetist. 

In  every  case  the  presence  of  acetonuria  or  other  acid  conditions 
should  be  ascertained  beforehand,  and  treatment  instituted  to  correct  the 
trouble  as  nearly  as  is  possible  before  the  anesthetic  is  administered. 
Elimination,  by  bowels,  kidneys,  and  skin,  should  be  stimulated  for  sev- 
eral days  previous  to  the  anesthesia,  and  the  tendency  to  hyperacidity 
should  be  counteracted  by  the  administration  of  suitable  alkaline  medica- 
tion. An  important  part  of  this  preparation  is  careful,  attention  to  the 
diet. 


414  ANESTHESIA 

Four  or  five  days  before  the  operation  tlie  patient  should  be  given 
sodium  bicarbonate,  fifteen  grains  daily,  until  the  urine  is  alkaline  in 
reaction.  Meats  should  be  restricted  or  excluded,  and  the  patient  placed 
upon  a  strictly  vegetable  diet  for  this  length  of  time.  Two  hours  before 
the  operation  a  saline  enema,  one  pint  or  more,  with  one  ounce  of  olive 
oil  and  one  ounce  of  glucose,  should  be  given.  One  hour  before  the 
operation  small  amounts  of  morphin  should  be  administered,  according 
to  the  patient's  condition.  (See  Preliminary  Medication,  p.  70.)  If 
chloroform  is  used  at  all,  it  should  be  used  only  in  the  beginning  of  the 
anesthesia,  and  a  change  should  be  made  to  ether  at  the  second  stage. 
The  rule  of  Mortimer  ^  in  connection  with  these  cases  is  a  good  one : 
"Never  give  chloroform  alone  except  for  rare  and  special  reasons."  Small 
amounts  of  chloroform  may  be  used  'until  the  second  stage  is  reached ; 
this  excludes  the  element  of  fear,  and  is  a  desirable  procedure  if  the 
psychic  element  is  very  much  in  evidence.  This  method  is  preferable 
to  inducing  the  anesthetic  with  ether,  which  might  give  rise  to  very  great 
fright  and  necessitate  holding  the  patient. 

Beven  and  Favill  ^  collected  over  twenty-nine  scattered  cases,  seem- 
ingly identical,  in  regard  to  acid  intoxication  and  late  poisoning  effects 
from  chloroform  and  ether  anesthetics.  The  first  case  reported  is  so 
typical  of  the  poisonous  after-effects  of  chloroform  that  all  the  facts  in 
connection  with  it  are  worthy  of  being  recorded. 

An  unusually  long  time  and  a  large  amount  of  the  anesthetic  were 
required  to  establish  surgical  narcosis.  The  time  of  narcosis  and  opera- 
tion is  not  stated,  but  the  patient  was  thoroughly  conscious  a  short  while 
afterward  with  a  pulse  of  102  and  a  temperature  of  101°.  About  two 
days  later  the  first  symptoms  of  poisoning  were  marked,  the  mother  of 
the  child  noticing  that  she  was  not  quite  natural  in  her  remarks.  The 
physicians  were  called,  and  found  the  child  talking  incoherently  and 
exhibiting  evidences  of  great  fright.  This  mental  condition  appeared 
without  warning,  as  all  symptoms  had  pointed  to  an  uneventful  recov- 
ery up  to  this  time  (44  hours  after  the  operation).  There  was  a  rising 
pulse,  with  unremitting  delirium  and  a  curious  shrieking  outcry.  The 
delirium  was  partly  controlled  by  small  amounts  of  morphin.  At  regu- 
lar intervals  a  period  of  excitement — practically  a  convulsion — would 
occur,  lasting  for  one  minute  or  perhaps  longer.  Death  occurred  110 
hours  after  the  operation,  with  a  gradually  rising  temperature,  irregu- 
lar and  rapid  pulse.  Cheyne-Stokes  respiration  was  present.  During  the 
last  two  days  before  the  child's  death  a  sweetish,  acetone  odor  was  noted 
on  her  breath. 

Other  Cases. — Several  clinicians  have  noted  symptoms  appearing 
from  two  to  six  days  after  chloroform  narcosis.     Violent  and  persistent 

^Mortimer:     "Anesthesia  and  Analgesia,"  65. 

^  Bevan,  Artliur  D.,  and  Favill,  Henry  B. :  J.  Am.  Med.  Assn.,  Sept.  2,  1905. 


TREATMENT  BEFORE,  DURING,  AND  AFTER  ANESTHESIA     415 

vomiting,  icterus,  sometimes  piercing  shrieks,  profuse  sweating,  and  a 
picture  of  terror  on  the  face  seemed  to  be  the  clinical  symptoms,  also 
air  hunger,  as  evidenced  by  deep  breathing  and  cyanosis.  Fatty  changes 
have  been  noted  in  liver,  heart,  or  kidneys,  or  all  of  these  organs,  on 
autopsy;  acute  yellow  atrophy,  fatty  denegeration,  or  fatty  infiltration 
of  the  liver  have  also  been  noted.  Death  usually  occurs  from  exhaus- 
tion, the  patient  sinking  into  a  state  of  coma  from  the  third  to  fifth  day. 
The  urine  contains  albumin  in  all  cases,  and  is  usually  scanty.  Probyn- 
Williams  ^  states  that,  while  deaths  have  followed  the  inhalation  of 
chloroform  more  frequently  than  any  other  anesthetic,  cases  have  been 
reported  with  both  ether  and  ethyl  chlorid.  Brewer  ^  reports  a  case  fol- 
lowing an  operation  for  acute  appendicitis. 

When  death  occurs  from  acidosis,"'  it  seems  to  be  due  to  lack  of  oxy- 
gen, as  there  is  struggling  for  breath  and  cyanosis.  The  symptoms  are 
vomiting,  sweetish  odor  of  breath,  face  flushed,  lips  dry,  weak,  rapid 
pulse,  restlessness,  unconsciousness.  In  children  the  acetone  is  given 
off  through  the  lungs.  In  adults  it  is  excreted  by  the  kidneys.  Pathol- 
ogy of  acidosis  is  fatty  degeneration  of  liver,  kidneys,  and  muscles.  Con- 
ditions Tinder  which  acidosis  may  occur :  Diabetes,  carcinoma,  digestive 
disturbances,  starvation,  gastric  ulcer,  excessive  fat  ingestion,  infec- 
tious fevers,  chronic  morphinism,  fatty  liver,  starvation  (lack  of  carbo- 
hydrates), and  following  ether  or  chloroform  anesthesia,  in  120  cases 
etherized  by  the  "cone  method,"  acetonemia  developed  in  88.5  per  cent. 
Of  the  same  number  with  the  drop  method  only  26  per  cent  showed 
acetonuria. 

^ Probyn-Williams :      "A  Practical  Guide  to  the  Administration  of  Anesthet- 
ics," 166. 

^Brewer:     Ann.  of  Surg.   (1902),  36,  481. 

^  Hamblen :      Univ.   of  Fenn.  Med.  Bull.,  .June,   1909. 


CHAPTER    X 

ANESTHESIA    BY    INTEATEACHEAL    INSUFFLATION 

Charles  A.  Elsberg,  M.D. 

Definition. 

History. 

The  Apparatus  for  Intratracheal  Anesthesia  in  the  Human 
Being  :  Apparatus  ISTo.  I ;  Apparatus  No.  II ;  The  Catheter  or  Tube 
to  Be  Used ;  The  Introduction  of  the  Tube. 

The  Course  of  the  Anesthesia. 

Errors  Which  May  Occur  in  Technique:  Accidents  and  How 
They  May  Be  Avoided. 

The  Indications  for  Intratracheal  Anesthesia. 

The  Value  of  Insufflation  of  Pure  Air  or  Air  and  Oxygen 
AS  A  Method  of  Artificial  Eespiration. 

Bibliography. 

Definition. — Intratracheal  insufflation  is  the  name  given  by  Meltzer 
and  Auer  to  a  method  by  means  of  which  a  mixture  of  air  and  ether 
is  driven  deep  into  the  trachea  by  means  of  external  pressure  through  a 
tube  which  has  been  introduced  into  the  trachea  through  the  larynx. 

History. — Physiological  Basis. — Animal  Experiments. — In  1909 
Meltzer  and  Auer  ^  first  published  an  account  of  their  experiments,  which 
culminated  in  the  method  of  anesthesia  to  which  they  gave  the  name 
"intratracheal  insufflation.'^  Physiologists  had  long  known  that  animals 
could  be  kept  alive  by  blowing  air  into  the  lungs,  but  this  method  had 
never  been  satisfactorily  applied  to  the  human  being.  Fell,  O'Dwyer, 
Kuhn,  Volhard,  and  others  attempted  to  apply  methods  of  this  kind  to 
man.  Hirsh,  Robinson,  and  others  showed  that  the  blood  could  be  well 
oxygenated  by  passing  a  stream  of  oxygen  intermittently  through  a  tube 
to  the  bifurcation  of  the  trachea. 

It  is  well  known  that  breathing  is  kept  up  by  alternating  respiratory 
movements  and  that  the  proper  ventilation  of  the  lungs  depends  upon 
the  normal  activity  of  the  muscles  of  respiration  and  the  intact  condi- 
tion of  the  walls  of  the  thorax.  Meltzer  and  Auer  discovered  that  the 
proper  exchange  of  the  air  in  the  lungs  can  be  accomplished  by  an 

^Meltzer  and  Auer:     J.  Eocper.  Med.,  1909,  11,  622. 

416 


ANESTHESIA  BY   INTRATRACHEAL   INSUFFLATION       417 

almost  continuous  stream  of  air  passing  in  one  direction.  They  found 
that  if  they  passed  a  tube  through  the  larynx  of  a  dog  almost  to  the 
bifurcation,  and  blew  air  through  this  tube  in  a  continuous  stream,  the 
animal  could  be  kept  alive  for  many  hours,  even  after  all  voluntary 
respiratory  movement  had  been  abolished  by  curare.  By  allowing  the 
stream  of  air  to  pass  over  the  surface  of  ether  in  a  bottle,  they  found  that 
animals  could  be  very  satisfactorily  anesthetized.  In  these  animals  it 
was  possible  to  open  both  pleural  cavities  widely  and  to  have  the  animals 
remain  alive  for  many  hours. 

The  apparatus  used  by  Meltzer  and  Auer  ^  was  a  very  simple  one. 


Fig.  155. — Meltzer's  Simple  Apparatus  for  Intratracheal  Insttfflation.  B,  foot- 
bellows;  S.  T,  stopcocks;  E,  ether  bottle  with  S.  C,  stopcock  and  F,  funnel;  M, 
manometer;  S.  V,  mercury  safety  valve;  IN-T,  intratracheal  tube. 


It  consisted  of  a  foot  bellows  connected  by  tubes  with  a  bottle  containing 
ether  and  with  a  mercury  manometer.  The  tubes  were  so  arranged  that 
more  or  less  of  the  air  from  the  bellows  passed  over  the  surface  of  the 
ether,  and  thus  became  more  or  less  saturated  with  ether  vapor.  The 
air  and  ether  mixture  was  blown  in  at  a  pressure  of  15  to  20  mm.  of 
mercury.  The  only  condition  essential  to  success  was  that  the  tube  be  of 
a  size  less  than  one-half  of  the  diameter  of  the  trachea,  so  that  the  air 
and  ether  which  passed  up  the  trachea  and  out  through  the  larynx  and 
mouth  in  a  continuous  stream  had  free  escape.  Later  it  was  found  of 
advantage  to  interrupt  the  stream  three  to  six  times  a  minute,  so  as  to 
allow  the  lungs  to  partially  collapse  for  a  moment  at  times,  and  thus 
to  get  rid  of  small  quantities  of  carbon  dioxid  which  are  apt  to  remain 
in  the  pulmonary  alveoli. 

With  this  simple  apparatus,  Meltzer  and  Auer  ^  made  many  investi- 

^  Meltzer  and  Auer:     J.  Exper.  Med.,   1909,  11,  622. 
^Med.  Bee,  1910,  77,  487. 


418  ANESTHESIA 

gations  upon  animals,  and  they  recommended  the  method  as  an  emi- 
nently safe  one  for  anesthesia.  They  pointed  out  that  it  might  have 
great  value  for  intrathoracic  operations,  and  that  it  was  an  ideal  method 
for  artificial  respiration.  Elsberg  ^  made  a  large  number  of  experiments 
on  animals,  and  performed  numerous  operations  upon  the  lungs  of  dogs, 
and  Carrel  ^  used  the  method  with  great  satisfaction  in  his  operative 
work  upon  the  heart  and  thoracic  blood  vessels  of  dogs.  In  all  of  these 
experiments  one  or  both  pleural  cavities  were  widely  opened,  the  heart 
action  remained  good  and  regular,  superficial  respiratory  movements  per- 
sisted. In  other  words,  the  method  of  intratracheal  insufflation  was  effec- 
tive in  preventing  collapse  of  the  lungs  when  the  thorax  was  opened. 
Later,  Nordman,^  Schlesinger,*  Boothby  and  Ehrenfried,^  Fischer,®  and 
others  investigated  upon  animals  the  value  and  advantages  of  the  method 
from  the  standpoint  of  the  anesthesia  and  with  regard  to  its  efficiency 
in  the  presence  of  a  single  or  double  pneumothorax.  The  reports  of  all 
these  authors  have  been  uniformly  in  favor  of  the  method. 

From  an  extensive  and  thorough  experimental  investigation  of  anes- 
thesia by  intratracheal  insufflation  of  air  and  ether,  Meltzer ''  concludes 
as  follows:  "The  essentials  of  the  method  of  intratracheal  insufflation 
consist^  in  the  introduction  deep  into  the  trachea  of  a  flexible  elastic 
tube,  the  diameter  of  which  has  to  be  much  smaller  than  the  lumen  of 
the  trachea,  and  ^  the  driving  through  this  tube  of  a  nearly  continuous 
stream  of  air  which  returns  through  the  space  between  the  tube  and  the 
walls  of  the  trachea.  The  distinguishing  features  of  this  method  consist 
in  the  following  two  new  principles:  1.  By  bringing  the  pure  air  di- 
rectly to  the  larger  bronchi,  and  by  driving  out  the  vitiated  air  from 
these  bronchi  through  the  force  of  the  returning  air  stream,  that  part 
of  the  "^death  space'  is  eliminated  which  is  represented  by  the  mouth, 
pharynx,  larynx,  and  trachea.  The  chief  aim  of  the  complicated  nervous 
and  muscular  mechanisms  of  respiration  is  to  establish  an  efficient  venti- 
lation, capable  of  overcoming  the  obstacles  offered  by  the  mentioned 
'death  space.'  A  well-arranged  intratracheal  insufflation  is  fully  capable 
of  relieving  and  replacing  the  normal  respiratory  mechanism.  2.  The 
practically  continuous  recurrent  air  stream  prevents  the  invasion  of  in- 
different or  infectious  foreign  matter  from  the  pharynx  into  the  trachea. 

'Elsberg:      Med.  Bee,  1910,  77,  493. 

'^  Carrel:     Med.  Bee,  1910,   77,  491;   J.  Am.  Med.  Assn.,  1910,  54,  28. 

='Nordman:     ArcMv  f.  Tclin.  CUr.,  1910,  92. 

*  Schlesinger :     Archiv  f.  Tclin.  Chir.,  1911,  95. 

'Ehrenfried:     Boston  Med.  and  Surg.  J.,  164,   532 

^Eischer:      Surg.  Gyn.  and  Ohstet.,  1911,  13,  566. 

'Meltzer:     J.  Am.  Med.  Assn.,  Aug.  12,   1911. 

« Meltzer  and  Auer:     J.  Exper.  Med.,   1909,  11,  622. 

^Meltzer:     J.  Am.  Med.  Assn.,  Aug.  12,  1911. 


ANESTHESIA  BY   INTRATRACHEAL   INSUFFLATION       419 


"The  usefulness  of  the  method  is  at  least  threefold.  1.  It  is  capable 
of  keeping  up  an  efficient  respiration  in  cases  in  which  the  normal  mech- 
anism of  external  respiration  fails.  3.  It  overcomes  efficiently  and  con- 
veniently the  difficulties  pre- 
sented by  double  pneumothorax. 
3.  It  offers  a  safe  and  reliable 
method  for  anesthesia,  especial- 
ly for  the  administration  of 
ether." 

Meltzer  and  Auer  and  the 
investigators  who  took  up  their 
work  thus  demonstrated  that  in 
animals  the  method  of  intra- 
tracheal insufflation  is  very  effi- 
cient both  for  anesthesia-  in  gen- 
eral and  for  thoracic  operations 
in  particular.  Its  first  applica- 
tions in  the  human  being  were 
made  by  Elsberg/  who  was  soon 
followed  by  other  surgeons  in 
the  United  States  and  else- 
where. 

The  Apparatus  for  Intra- 
tracheal Anesthesia  in  the  Hu- 
man Being. — A  very  simple  ap- 
paratus constructed  upon  the 
plan  of  the  one  used  in  the  lab- 
oratory can  easily  be  put  to- 
gether by  anyone.  Such  an  ap- 
paratus would  suffice  in  an 
emergency.  The  construction 
and  working  of  the  one  sug- 
gested by  Meltzer  can  be  easily 
understood  from  the  diagram 
(see  Fig.  155).  For  general  use 
in  the  human  being,  a  more 
complete  apparatus  is  necessary,  one  that  cannot  get  out  of  order,  and 
which  is  surrounded  by  every  possible  safeguard  in  case  of  trouble  with 
any  of  its  parts. 

The  essentials  for  such  an  apparatus  are:  (1)  A  source  of  air  (elec- 
tric blower,  foot  bellows,  hand  pump)  ;  (2)  a  system  of  tubes  connected 
with  an  ether  reservoir  and  a  mercury  manometer;  (3)  a  regulator  or 
automatic  blow-off  that  should  prevent  too  great  pressure  in  the  tubes; 

^Elsberg:     Am.  Surg.,  Feb.,  1911;  June,  1911;   Dec,  1911. 


Fig.    150.- 


-Elsberg's  Appaeatus,   for  Hos- 
pital Use. 


420 


ANESTHESIA 


(4)    a  warm  water  tank,  by  means  of  which  the   air  stream  can  be 
warmed  and  moistened. 

For  hospital  use,  it  is  advisable  to  have  an  apparatus  which  works 
automatically,  and  to  reserve  the  foot  bellows  as  an  addition  which  can 
be  used  if  the  motor  and  blower  are  out  of  order,  or  if  there  is  no  elec- 
tric current.  Elsberg  devised  two 
forms  of  apparatus,  viz.:  (1)  an  ap- 
paratus meant  for  hospital  use;  (2) 
a  smaller  and  more  easily  portable  ap- 
paratus. A  description  of  these  fol- 
lows. 

Apparatus  No.  1  (see  Figs.  156 
and  157). — The  entire  apparatus  is 
contained  in  a  wooden  box  38^/^ 
inches  long,  11  inches  deep,  and  18 
inches  wide.  It  is  easily  transport- 
able. The  box  is  placed  on  the  floor 
near  the  head  end  of  the  operating 
table,  and  the  front  is  turned  down^ 
in  order  to  expose  the  interior, 
which  contains  the  following  (Fig. 
157).  By  means  of  the  switch  A  and 
the  rheostat  B  the  electric  current  is 
carried  to  the  1/6  horsepower  motor 
C,  which  drives  the  blower  D.  The 
air  passes  through  the  tube  E  and  the 
oil  filter  F  and  the  tube  G  into  the 
bottle  H.  This  bottle  contains  hot 
water,  so  that  the  air,  as  it  bubbles 
through  the  water,  is  warmed,  washed, 
and  moistened.  The  current  of  air 
then  passes  through  the  tube  I  to  the 
rubber  tube,  which  is  connected  to  the  intratracheal  catheter.  To  this 
tube.  No.  1,  is  connected  the  ether  reservoir  J. 

The  ether  reservoir  consists  of  a  glass  jar,  which  is  held  air-tight 
against  its  cover  by  a  spring  clamp  below.  The  cover  contains  the  open- 
ings of  two  tubes  (X,  X'),  which  are  connected  with  the  main  tube  I. 
The  hand  wheel  K,  which  moves  an  indicator  on  a  scale  above  it,  is  ar- 
ranged to  control  the  air  passing  through  the  tube  I.  When  the  indi- 
cator stands  at  zero  at  the  scale,  pure  air  is  passing  through  the  tube  I. 
As  the  indicator  is  turned,  more  and  more  of  the  air  is  diverted  into  the 
one  tube  (X),  which  leads  into  the  ether  reservoir.  When  full  ether  is 
turned  on,  all  of  the  air  has  to  pass  into  the  ether  reservoir  and  over  the 
^  The  box  is  now  arranged  so  that  the  front  can  be  entirely  removed. 


Fig.  157. — Diagram  to  Explain  the 
Parts  of  Elsberg's  Apparatus 
No.  1.  The  letters  refer  to  the 
letters  in  the  text. 


ANESTHESIA  BY    INTRATRACHEAL   INSUFFLATION       421 

surface  of  the  ether,  so  that  it  becomes  saturated  with  ether  vapor. 
When  the  indicator  shows  that  pure  air  is  passing  through  the  tube  I, 
the  tubes  which  lead  into  the  ether  reservoir  are  closed,  and  the  ether 
reservoir  can  be  removed  if  necessary  and  refilled. 

The  manometer  L  is  connected  with  the  tube  I,  and  records  the 
pressure  of  the  air  current  which  is  flowing  through  it.    The  ends  of  the 


Fig.  158. — Elsberg's  Simplified  Portable  Apparatus  for  Intratracheal  Insuffla- 
tion.    To  show  the  motor  and  blower. 

manometer  tube  have  hard  rubber  stopcocks,  which  can  be  closed  when 
the  apparatus  is  to  be  transported — a  possible  spilling  of  the  mercury  in 
the  manometer  being  thus  prevented. 

The  tube  M  leads  into  the  main  tube  G  and  has  also  a  stopcock,  and 
to  its  tip  the  tube  from  an  oxygen  tank  can  be  connected  so  that  oxygen 
can  be  added  to  the  air  if  desired.  The  tube  P  leads  to  a  foot  bellows, 
which  has  been  added  to  the  apparatus  as  a  safety  device  if  anything 
should  happen  to  the  motor  or  blower,  or  to  be  used  where  no  electric 
current  is  available.  When  the  stopcock  N  is  closed  and  0  is  opened, 
and  the  foot  bellows  used,  the  air  passes  into  the  tube  G'  and  into  the 
water  bottle.    When  the  stopcock  IST  is  open  and  0  is  closed,  no  air  can 


422 


ANESTHESIA 


enter  the  main  tube  from  the  bellows,  and  air  passes  to  the  water  bottle 
from  the  blower.  It  takes  only  a  moment  to  turn  the  two  stopcocks 
so  that  one  can  instantly  switch  from  air  from  the  blower  to  air  from  the 
foot  bellows  and  vice  versa. 

The  water  bottle  H  is  held  firmly  in  place  by  a  clamp.     The  tubes 
from  it  are  connected  to  the  main  tube  by  bayonet  points,  so  that  the 


Fig.  159. — Elsberg's  Apparatus.     Lower  compartment  closed. 


bottle  can  be  easily  removed  when  it  is  to  be  filled  or  emptied.  The  per- 
forated cork  is  held  firmly  and  air-tight  by  a  clamp. 

The  apparatus  and  its  handling  are  simple.  When  it  is  to  be  used, 
the  water  bottle  is  first  one-third  filled  with  hot  water,  the  stopcocks 
on  the  manometer  opened,  the  stopcock  JST  opened  and  0  closed,  the 
switch  turned  on,  the  rheostat  turned  on  full,  and  the  motor  and  blower 
thus  set  in  motion.  The  stopcock  M  is  left  wide  open.  As  soon  as  the 
apparatus  has  been  connected  with  the  intratracheal  tube  the  stopcock 
M  is  slowly  turned  until  the  manometer  shows  that  the  pressure  of  the 
air  is  20  mm. 

The  percentage  of  ether  is  regulated  according  to  the  depth  of  the 
anesthesia ;  usually  the  indicator  has  to  be  turned  until  it  shows  that  half 
or  full  ether  is  being  used. 

By  means  of  the  stopcock  at  I  (below  the  manometer),  the  air  and 


ANESTHESIA  BY   INTRATRACHEAL   INSUFFLATION       423 

ether  current  can  be  diverted  from  the  iiitralrachcal  tube  so  that  no  air 
enters  the  intratracheal  tube,  but  all  of  it  escapes  through  the  open  stop- 
cock. 

The  management  of  this  apparatus  is  extremely  easy.  From  the  mo- 
ment the  power  is  turned  on  and  the  pressure  regidated,  the  anes- 
thetist's principal  duties  consist  in  watching  the  pressure  gauge  and 
occasionally  interrupting  the  current  of  air  so  as  to  momentarily  collapse 
the  lungs.  He  can  be  seated  near  the  table  so  as  to  observe  the  pulse  of 
the  patient. 

Apparatus  No.  2. — This  apparatus  is  much  smaller  than  No.  1.  It 
can  be  easily  carried  around  like  a  handbag.  It  is  21  inches  high,  20 
inches  broad,  and  9^/2  inches  wide  (Figs.  158  and  159).  The  apparatus 
is  similar  to  No.  1,  but  is  much  lighter  and  nnich  more  compact.  The 
motor  and  blower  are  underneath  in  a  closed  compartment.  At  A  the 
foot  bellows,  which  lies  in  a  compartment  above,  is  to  be  attached.  B  is 
the  stopcock  for  regulating  the  pressure,  C  is  a  simple  lever  by  which  the 
anesthetizer  can  switch  from  air  from  blower  to  air  from  bellows.  The 
lube  D  leads  into  the  metal  water  tank  in  the  inside  of  the  box.  E  is 
the  ether  reservoir  held  by  the  eccentric  below.  Above  this  is  the  ether 
regulator.  F  is  the  manometer,  G  the  safety  valve  allowing  regulation  of 
pressure.     H  is  the  stopcock  for  making  interruptions  of  the  current.^ 

The  apparatus  of  Janeway  is  very  complete,  but  very  complicated 
(Figs.  160A  and  B).  The  following  description  will  serve  to  explain  the 
various  parts  of  the  machine.  No.  1  is  a  motor  which  turns  the  wing 
blower  2.  From  the  blower  the  air  passes  through  the  air  filter  and 
muffler  3.  By  the  valve  4  the  current  of  air  may  be  divided  into  two 
reciprocally  varying  quantities;  one  portion  passes  directly  over  the 
heated  water  (heated  by  electricity)  in  jar  5,  while  the  other  portion 
passes  through  jar  5,  after  first  passing  over  the  surface  of  ether  in  jar  6. 
Thus  the  whole  current  of  air  or  any  desired  proportion  may  be  mixed 
with  ether,  and  in  this  manner  varying  quantities  of  ether  supplied  to 
the  patient.  Provision  is  also  afforded  for  still  further  saturating  the  air 
with  ether  by  valve  7,  which  is  so  arranged  that  a  small  quantity  of  the 
air  passing  through  jar  6  may  be  made  to  bubble  through  only  the 
top  layers  of  the  ether  irrespective  of  the  level  of  the  ether  in  the  jar. 
The  blow-off  valve  8  prevents  any  injurious  excess  of  pressure,  and  valve 
9,  operated  by  worm  wheel  10,  mechanically  interrupts  the  current  of 
air  passing  to  the  patient  at  any  desired  intervals. 

In  Fischer's  apparatus  (Fig.  161)  the  air  pressure  is  obtained  by 
means  of  a  hand  pump.  Fischer  published  a  complete  description  of  his 
apparatus,^  but  a  study  of  Figure  161  will  allow  the  reader  to  gain  a  fair 
idea  of  it. 

^  A  full  description  of  this  apparatus  will  be  found  in  the  Ann.  Surg.,  1912. 
^  Surg.  Gynec.  and  Obstet.,  Nov.,   1911. 


Fig.   160a. 


Fig.   160b. 
Fig.  160a  and  b. — Janeway's  Apparatus. 


ANESTHESIA  BY   INTRATRACHEAL   INSUFFLATION       425 

Ehrenfried's  apparatus  (Fig.  162)  has  the  merits  of  simplicity,  but, 
like  Fischer's  apparatus,  has  no  safety  device  by  means  of  which  the 
method  can  be  continued  if  any  part  of  the  main  apparatus  is  broken 
or  out  of  order. 

The  Catheter  or  Tube  to  Be  Used. — The  tube  which  is  to  be  in- 
troduced into  the  trachea  must  be  fairly  rigid,  so  that  it  cannot  be 
coughed  out  of  the  trachea  when  it  is  once  in  place.  A  soft  rubber  tube 
should  never  be  used.  Not  only  is  the  introduction  of  a  soft  rubber  tube 
more  difficult,  but  it  is  not  rigid  enough,  as  it  might  be  compressed  if  a 
spasm  of  the  larynx  should  occur.  The  ordinary  silk- woven  urethral 
catheter  with  a  side  opening  near  its  end  fulfills  all  requirements.    It  has 


Fig.  161. — Fischer's  Apparatus.     The  handle  of  the  hand  pump  is  not  shown  in  the 

photograph. 

the  additional  advantage  that  it  can  be  obtained  everywhere.  The  cathe- 
ter should  have  two  marks  upon  it — one  13  centimeters  and  a  second  26 
centimeters  from  the  tip.  The  average  length  of  the  adult  trachea  is  12 
to  13  centimeters ;  of  the  thyroid  cartilage,  5  centimeters ;  of  the  distance 
from  the  incisor  teeth  to  the  glottis,  14  centimeters.  Therefore,  if  the 
tip  of  the  intratracheal  tube  is  26  to  27  centimeters  from  the  incisor 
teeth,  it  will  lie  about  5  centimeters  or  less  above  the  bifurcation  of  the 
trachea. 

The  size  of  the  catheter  must,  of  course,  vary  with  the  diameter  of 
the  trachea  and  the  size  of  the  larynx.  For  the  adult,  it  is  advisable  to 
use  a  tube  of  the  size  24  of  the  French  scale.  The  diameter  of  this  size 
of  tube  corresponds  to  about  one-half  of  the  length  of  the  glottis,  as  seen 
through  the  direct  laryngoscope.  Sometimes  a  somewhat  larger  cathe- 
ter must  be  used,  but  it  is  always  better  to  use  a  tube  that  is  too  small 
than  one  that  is  too  large. 

In   children   the   catheter   must   be   correspondingly   smaller.      The 


426 


ANESTHESIA 


length  of  the  catheter  in  the  trachea  will  vary  with  the  size  of  the  child, 
but  it  has  been  found  that  in  general  the  length  of  the  catheter  that 
should  be  below  the  glottis  measures  about  the  same  as  the  length  of 
the  tube  from  the  glottis  to  the  incisor  teeth.     In  other  words,  if  the 


^0fUm  ^^3_ 

1^ 

Fig.  162. — Ehrenfried's  Apparatus  for  Intratracheal  Etherization.  (Driven  by 
foot  pump  which  is  not  shown  in  the  photograph.)  It  consists  essentially  of  a  copper 
hot-water  jacket,  holding  a  Wolffe  bottle  containing  ether.  There  are  cocks  by  which 
the  air  from  the  bellows  may  be  sent  in  any  proportion  through  a  coil  in  the  hot  water, 
over  the  surface  of  the  ether,  or  made  to  bubble  through  ether.  Attached  to  the 
outside  of  the  jacket  is  a  mercury  bottle  safety-valve.  On  the  delivery  tube  is  a  con- 
trivance to  filter  the  air  and  to  prevent  droplets  of  condensed  ether  from  being  car- 
ried over  into  the  lungs. 

catheter  has  been  introduced  as  far  as  the  glottis,  it  will  have  to  be 
pushed  again  as  far  downward  as  to  have  the  tip  in  the  proper  part  of 
the  trachea. 

The  Introduction  of  the  Tube. — In  many  patients  it  is  possible  to 


'^/^*:st^ 


Fig.    163. — Cotton-Boothby    Introducing    Cannula,    Ehrenfried's    Modification, 
FOR  Soft-Rubber  Tubes. 


introduce  the  catheter  after  the  epiglottis  has  been  pulled  forward  by 
means  of  the  index  finger,  which  acts  also  as  a  guide.  In  children  the 
intubation  is  always  easy  by  this  means.     In  many  adults  the  epiglottis 


ANESTHESIA  BY   INTRATRACHEAL   INSUFFLATION       427 


cannot  be  reached  by  the  finger;  in  these  patients  the  intubation  is  im- 
possible by  touch  alone,  and  a  special  instrument  must  be  used.  Vari- 
ous guides  with  a  laryngeal  curve  and  variously  shaped  laryngeal  forceps 
have  been  tried.  None  of  these  has  been  uniformly  satisfactory,  but 
Boothby  and  Cotton  recommend  their  introducer  (see  Fig.  103),  and 
Ehrenfried  has  one  of  his  own  (Fig.  164).  I  have  found  that  the  tube 
can  always  be  quickly  and  easily  introduced  when  the  larynx  is  in  plain 
view,  which  can  be  easily  accomplished  by  means  of  the  Jackson  direct 
laryngoscope  (see  Figs.  92  and  1G5).  With  a  very  little  practice,  one 
can  learn  to  use  this  instrument  and  obtain  an  admirable  view  of  the 
glottis,  so  that  the  catheter  can  be  readily  introduced  between  the  vocal 
cords.     Anyone  who  is  to  use  the  method  of  intratracheal  anesthesia 


Fig.   164. — Ehrenfried's  Introducing  Forceps  for  Stiff  or  Soft-Rubber  Tubes. 

should  practice  the  method  of  the  exposure  of  the  larynx  with  the  Jack- 
son instrument. 

If  the  larynx  is  well  cocainized  it  is  possible  to  introduce  the  cathe- 
ter and  anesthetize  the  patient  by  means  of  intratracheal  insufflation  of 
the  anesthetic.  The  introduction  of  the  tube  is  unpleasant,  however,  and 
the  beginning  of  the  insufflation  may  cause  the  patient  much  discomfort 
because  of  the  reflexes  at  the  bifurcation  of  the  trachea.  In  the  cases 
where  a  preliminary  anesthesia  by  inhalation  is  inadvisable  (where  there 
is  danger  of  collapse  of  the  trachea,  etc.),  the  best  plan  to  follow  is  to 
introduce  the  catheter  after  the  larynx  has  been  well  cocainized;  then 
to  anesthetize  the  patient  by  means  of  ether  given  through  a  mask  or 
cone  held  over  the  end  of  the  catheter  and  the  mouth. 

In  general,  it  is  best  to  give  the  patient  a  dose  of  morphin  and 
atropin  and  then  to  anesthetize  him  in  the  usual  manner  Avith  ether. 
When  the  patient  is  well  under  anesthesia,  he  is  brought  into  the  operat- 
ing room  and  placed  upon  the  operating  table,  with  the  head  hanging  well 
downward  over  the  end  of  the  table  and  the  mouth  held  open  with  an  or- 
dinary mouth  gag.^     The  direct  laryngoscope  is  then  introduced  and 

^  Preliminary  cocainization  of  the  larynx  is  unnecessary. 


428 


ANESTHESIA 


pushed  along  the  posterior  wall  of  the  pharynx  until  the  epiglottis  is  in 
plain  view.  The  epiglottis  is  pulled  well  forward  by  the  beak  of  the 
instrument  and  the  glottis  well  exposed.  One  usually  obtains  a  fine 
view  of  the  larynx,  can  clearly  see  the  opening  between  the  cords,  and  can 


^^MWMjWi 


Fig.  165. — Jackson's  Direct  Laryngoscope.     (See  p.  226.) 

estimate  its  size  and  length.  If  there  is  any  difficulty  in  exposing  the 
vocal  cords,  the  head  and  neck  are  pulled  forward  as  a  whole,  the  head 
being  kept  bent  backward  as  before.  A  catheter  whose  outside  diameter 
measures  about  one-half  of  the  length  of  the  glottis    (in  general  No. 


Fig.  166. — Elsberg's  Clip  to  Hold  the  Intratracheal  Tube  in  Place.  The  rubber 
covered  arms  B  B'  lie  between  the  teeth  and  hold  the  tube  between  them.  The  wires 
W  W  fit  over  the  ears  like  the  wires  of  spectacles. 

24  F  can  be  used)  is  then  selected.  This  is  introduced  through  the  laryn- 
goscope and  into  and  through  the  larynx.  The  tube  is  then  pushed  for- 
ward until  the  second  mark  on  it  shows  that  the  tip  is  3  to  5  centimeters 
above  the  bifurcation  of  the  trachea.  Air  will  now  be  heard  rushing 
in  and  out  through  the  catheter.    The  patient  is  very  apt  at  this  time  to 


ANESTHESIA  BY   INTRATRACHEAL   INSUFFLATION       429 

have  an  attack  of  spasmodic  coughing  and  to  hold  his  breath.  This  need 
not  cause  concern,  as  respiration  will  soon  begin  again.  One  must  be 
sure  that  the  tube  is  in  the  trachea  and  not  in  the  esophagus.  If  one  is 
in  doubt,  the  catheter  must  be  withdrawn  and  reinserted.  One  soon 
learns,  however,  to  recognize  the  sound  of  the  air  rushing  in  and  out 
through  the  tube. 

The  tube  is  now  held  in  place  and  the  laryngoscope  withdrawn,  the 
entire  manipulations  thus  far  having  occupied  only  a  minute  or  two. 
The  patient  is  then  pulled  back  upon  the  operating  table. 

A  small  clip  serves  to  hold  the  catheter  in  place  (see  Fig.  166).  It 
consists  of  a  clip  bent  at  right  angles,  the  branches  covered  by  rubber 
tubing.  This  fits  between  the  teeth  so  that  the  patient  cannot  bite  the 
catheter,  which  is  held  firmly  in  place.  The  clip  is  held  in  position  by 
elastic  wires,  which  fit  over  the  ears  like  a  pair  of  spectacles.  After  the 
clip  is  in  place  the  mouth  gag  is  removed,  the  catheter  is  connected  with 
the  connecting  tip  of  the  tube  which  leads  from  the  insufflation  appa- 
ratus, and  from  which  the  mixture  of  air  and  ether  is  flowing,  and  the 
insufflation  is  begim. 

The  Course  of  the  Anesthesia. — Ether  is  the  safest  anesthetic  to  use 
for  intratracheal  insufflation.  The  dosage  of  chloroform  has  not  yet 
been  sufficiently  well  worked  out.  Nitrous  oxid  and  air  or  oxygen  can 
also  be  given  by  insufflation.  The  ether  anesthesia  is  usually  very  sat- 
isfactory. The  patients  are  quiet,  their  musculature  is  relaxed,  they 
breathe  quietly  and  superficially.  Some  respiratory  movements  should 
always  persist,  and  the  anesthetizer  should  never  keep  the  pressure, 
as  shown  by  the  manometer,  so  high  that  active  breathing  ceases  alto- 
gether. 

If  the  catheter  that  has  been  introduced  into  the  trachea  is  of  cor- 
rect size  and  in  the  proper  position,  the  face  of  the  anesthetized  patient 
will  be  of  a  pink,  rosy  color,  with  the  veins  of  the  forehead  slightly  prom- 
inent. The  pulse  is  full,  bounding,  and  regular.  If  the  patient  is  cya- 
nosed,  it  means  that  the  tube  is  not  deep  enough  in  the  trachea  or  that 
too  large  a  tube  has  been  used. 

When  the  insufflation  is  begun,  the  patient  may  have  a  short  attack 
of  spasmodic  coughing.  This  need  cause  no  concern,  and  the  insuflla- 
tion  can  be  continued.  The  cough  will  sometimes  persist  if  the  end  of 
the  intratracheal  tube  is  too  near  the  bifurcation;  it  must  then  be  with- 
drawn one  or  two  centimeters. 

There  is  a  complete  absence  of  mucus  rattling  in  the  throat  during 
the  entire  period  of  the  insufflation. 

It  is  advisable  to  insufflate  pure  air  for  a  few  minutes  at  the  end  of 
the  anesthesia  in  order  to  blow  out  the  anesthetic  from  the  lungs  and 
trachea.  Then  the  patients  will  awaken  very  quickly;  they  will  often 
answer  questions  before  the  dressings  have  been  applied.     When  the  in- 


430  ANESTHESIA 

tratracheal  tube  is  withdrawn,  there  is  often  a  short  period  of  apnea, 
then  regular  deep  breathing  again  begins. 

Cough  and  expectoration  do  not  occur  after  anesthesia  by  intra- 
tracheal.  insufflation  unless  the  patient  had  a  pulmonary  lesion  before 
the  operation,-  or  an  operation  was  performed  upon  the  lungs.  No  pul- 
monary complications,  of  even  the  mildest  kind,  have  been  observed  in 
more  than  500  anesthesias.  As  soon  as  the  patients  are  awake,  they 
speak  freely,  are  not  hoarse,  and  do  not  complain  of  pain  or  discomfort 
in  the  throat.  The  larynx  and  trachea  have  a  remarkable  tolerance  for 
the  tube,  which  can  remain  in  place  for  hours  without  danger. 

Post-operative  vomiting  is  certainly  quite  unusual  after  intratracheal 
insufflation.  This  is  probably  due  to  the  fact  that  no  ether  vapor  can 
be  swallowed. 

The  patients  seem  to  be  less  apt  to  show  symptoms  of  shock  than 
those  anesthetized  for  long  operations  by  ether  inhalation.  They  are 
never  too  deeply  under  the  anesthetic;  in  no  instance  has  dilatation  of 
the  pupils  as  an  evidence  of  too  deep  an  anesthesia  been  observed. 

Occasionally,  with  patients  upon  whom  an  abdominal  operation  is 
to  be  performed,  complete  relaxation  of  the  abdominal  muscles  is  not 
obtained.  These  patients  will  also  be  found  to  be  refractory  to  ether 
anesthesia  by  inhalation. 

Errors  Which  May  Occur  in  Technique. — When  the  technique  of 
intratracheal  insufflation  is  once  learned  and  the  apparatus  used  by  the 
anesthetizer  is  understood,  errors  or  accidents  should  never  occur.  Spe- 
cial attention  must  be  paid  to  the  following  features  of  the  method. 

The  catheter  that  is  used  should  be  too  small  rather  than  too  large, 
so  that  there  is  never  an  interference  with  the  free  escape  of  the  air  and 
ether  by  the  side  of  the  tube  and  out  through  the  larynx  and  mouth.  If 
the  proper  size  of  intratracheal  tube  is  used,  there  should  be  no  danger 
of  the  over  distention  of  the  lungs.  The  Elsberg  apparatus  is  arranged 
so  that  no  excess  of  pressure  in  the  lungs  can  occur.  Every  apparatus 
should  have  an  automatic  safety  valve  or  blow-off,  to  act  as  a  safeguard 
against  a  temporary  or  prolonged  over-pressure,  which  might  be  injuri- 
ous to  the  lung  tissue. 

Accidents,  and  How  They  May  Be  Avoided. — The  accidents  that 
have  occurred  so  far  have  been  due  to  errors  in  technique.  In  the  case  of 
Fischer,^  one  of  the  tubes  which  led  into  the  ether  reservoir  was  under 
the  surface  of  the  ether,  and,  by  turning  the  wrong  stopcock,  pure  ether 
was  blown  into  the  lungs.  The  tubes  which  lead  into  the  ether  bottle 
should  never  be  below  the  surface  of  the  ether;  in  fact  it  is  only  neces- 
sary that  they  reach  into  the  cover  of  the  ether  reservoir. 

In  three  other  cases,  two  of  which  resulted  fatally,  the  pressure  was 
too  high,  so  that  injury  to  the  lung  tissue  and  emphysema  in  the  sub- 

^Loc.  cit. 


ANESTHESIA  BY   INTRATRACHEAL   INSUFFLATION       431 

cutaneous  tissue  resulted.  This  could  not  have  occurred  if  tin;  appa- 
ratus had  been  provided  with  a  safety  valve  for  the  prevention  of  excess 
of  pressure.  In  one  of  the  cases  an  intratracheal  soft  rubber  tube 
was  pushed  down  until  it  completely  filled  one  of  the  branches  of 
a  bronchus,  allowing  no  air  to  escape.  With  a  proi)er  a|)])aratus  and 
the  proper  technique,  all  these  accidents  could  have  been  avoided.  In 
Mt.  Sinai  Hospital  almost  500  patients  have  been  anesthetized  without 
accident. 

Another  advantage  of  the  method  of  intubation,  in  which  the  vocal 
cords  are  brought  into  view,  is  that  the  catheter  can  be  introduced  when 
the  glottis  is  open,  no  force  being  necessary  in  pushing  it  down  into  the 
trachea. 

It  need  hardly  be  mentioned  that  one  must  be  sure  that  the  tube  is 
in  the  trachea  and  not  in  the  esophagus,  otherwise  overdistention  of  the 
stomach  could  easily  occur.  It  is  probable,  however,  that  in  such  a  case 
the  air  would  be  regurgitated  as  fast  as  it  entered  the  stomach. 

The  anesthetizer  should  never  give  an  anesthetic  by  insufflation  un- 
less he  thoroughly  understands  the  working  of  the  apparatus  he  is  using, 
nor  should  he  forget  to  interrupt  the  entering  stream  of  air  and  ether 
3  to  4  times  a  minute. 

To  sum  up  particular  points  to  which  attention  must  be  paid,  the 
anesthetizer  must  be  certain:     (1)  That  the  catheter  is  in  the  trachea; 

(2)  that  it  is  not  too  far  down — too  near  to  or  beyond  the  bifurcation; 

(3)  that  there  is  a  safety  valve  on  his  apparatus;  (4)  that  the  interrup- 
tions in  the  air  stream  are  made;  (5)  that  respiratory  movements  per- 
sist. 

The  Indications  for  Intratracheal  Anesthesia. — Anesthesia  by  intra- 
tracheal insufflation  is  of  value : 

(1)  In  thoracic  surgery  (whenever  the  thoracic  cavity  has  to  be  in- 
vaded, to  prevent  the  collapse  of  the  lungs). 

(2)  In  operations  upon  the  head  and  neck,  where  the  anesthetizer 
can  be  out  of  the  way  or  where  the  giving  of  the  anesthetic  is  ordinarily 
difficult,  as  in  bilateral  suboccipital  craniotomy  or  laminectomy,  where 
the  patient  has  to  lie  flat  on  the  abdomen. 

(3)  It  is  almost  indispensable  in  those  operations  in  the  mouth  where 
the  pharynx  and  larynx  must  be  kept  free  of  fluid  or  blood.  The  stream 
of  air  and  ether  which  is  continually  escaping  from  the  larynx  and 
mouth  blows  out  any  blood  that  might  run  down  the  throat,  so  that  the 
operator  need  have  no  fear  of  any  passing  into  the  trachea.  In  such 
operations  as  complete  removal  of  the  tongue,  removal  of  the  upper  or 
lower  jaw,  excision  of  malignant  disease  of  the  tonsil,  the  intranasal  or 
intrabuccal  approach  to  the  hypophysis,  etc.,  packing  the  pharynx  is 
unnecessary.  These  operations  are  made  much  easier  when  the  patient 
is  anesthetized  by  the  intratracheal  method.    The  tube  is  kept  in  one  cor- 


432  ANESTHESIA 

ner  of  the  moutH,  and  is  never  in  the  way  of  the  operator.    In  the  opera- 
tion of  laryngectomy,  intratracheal  anesthesia  is  advisable. 

(4)  Operations  around  the  trachea,  especially  removal  of  the  thy- 
roid gland,  can  be  made  much  easier  when  the  patient  is  anesthetized  by 
intratracheal  insufflation.  The  interference  with  the  smoothness  of  the 
anesthesia  when  the  trachea  is  pressed  or  pulled  upon  is  avoided,  and 
there  is  no  danger  of  collapse  of  the  trachea. 

(5)  In  operations  in  which  there  is  danger  of  vomiting  and  aspira- 
tion of  vomited  material.  Thus  in  operations  for  intestinal  obstruction 
done  under  intratracheal  anesthesia,  the  danger  of  the  patients  "drown- 
ing'^ in  their  own  vomitus  is  avoided. 

(6)  In  prolonged  operations,  and  with  cachectic  individuals.  Shock 
seems  particularly  rare  in  patients  anesthetized  by  this  method. 

The  future  may  show  that  intratracheal  anesthesia  will  have  a  still 
larger  field  of  usefulness  than  that  here  outlined. 

The  Value  of  Insufflation  of  Pure  Air  or  Air  and  Oxygen  as  a  Method 
of  Artificial  Respiration. — This  is  a  feature  upon  which  too  little  stress 
has  thus  far  been  laid.  Whenever  there  is  need  for  prolonged  artificial 
respiration,  such  as  in  opium  poisoning,  drowning,  etc.,  the  method  will 
surely  be  very  useful.  In  several  instances  we  have  kept  patients  alive 
in  good  condition  for  three,  four,  six,  or  seven  hours  although  during 
that  time  not  a  single  respiratory  movement  was  made.  The  color  of 
the  patient  remained  pink,  and  the  blood  was  well  aerated.  It  is  a 
valuable  characteristic  of  this  method  that  the  patients  need  not  breathe 
in  order  to  have  oxygenation  of  the  blood  occur,  the  apparatus  doing 
the  breathing  for  them.  In  this  respect  the  method  differs  from  all 
others  for  this  purpose.  It  may  be  added  that  it  has  the  same  advantage 
over  both  the  positive  and  negative  pressure  methods  for  thoracic  surgery. 
In  the  latter  the  respiratory  movements  of  the  patient  are  absolutely 
necessary,  aeration  of  the  blood  being  impossible  without  them.  With 
intratracheal  insufflation  oxygenation  of  the  blood  will  occur  just  as  well 
whether  or  not  the  patient  makes  respiratory  movements. 

BIBLIOGRAPHY 

Boothby  and  Cotton:    Surg.  Gynec.  and  Obstet.,  1911,  IS. 

Elsberg:    Langenbech's  Arcliiv,  1911. 

linger:    Berl.  Tclin.  Wocli.,  1910,  1748, 

Woolsey:    N.  Y.  State  J.  Med.,  Apr.,  1912,  12,  No.  4,  167. 


CHAPTEE    XI 

ANESTHESIA     BY     COLONIC     ABSORPTION     OF     ETHER     AND     OIL- 
ETHER    COLONIC    ANESTHESIA 


PAET    I 

ANESTHESIA    BY    COLONIC    ABSORPTION    OF    ETHER 

Walter  S.  Sutton,  A.B.,  A.M.,  M.D.,  F.A.C.S. 

History. 

The  Physiology  of  Colonic  Anesthesia. 

Development  of  the  Method. 

Sutton's  Apparatus  :     The  Generator. 

The  Afferent  and  Efferent  Tube  Systems. 

Technique  of  Method:    Preparation  of  the  Patient;  The  Admin- 
istration ;  After-treatment. 

Discussion  of  Cases. 

Conclusions  :  Indications ;  Contra-indications ;  Advantages ;  Dis- 
advantage. 
.  History. — The  high  efficiency  of  the  intestinal  mucous  membrane  of 
vertebrates  in  general  as  a  transmitter  of  gases  to  and  from  the  blood 
stream  has  long  been  recognized.  As  early  as  1808  Erman  ^  opened  the 
abdomen  of  cohitus  fossilis,  and  observed  that  when  air  was  swallowed 
the  liver  and  the  intestinal  veins  of  the  fish  became  bright  red;  while 
when  hydrogen  or  nitrogen  was  substituted  the  color  of  the  organs 
changed  to  dark  purple.  Baumert,^  in  1855,  analyzed  the  gas  passed 
per  rectum  by  the  same  kind  of  fish,  and  found  a  marked  decrease  in  the 
oxygen  content  and  corresponding  increase  in  nitrogen  when  swallowing 
of  air  had  been  prevented  for  several  hours.  Jobert,^  in  1877,  discov- 
ered that  in  callichthys  asper,  a  Brazilian  fish,  air-swallowing  is  essen- 
tial to  life,  the  fish  dying  in  about  two  hours  if  prevented  from  the  exer- 
cise of  this  form  of  accessory  respiration.     In  mammals,  also,  similar 

*  Erman:     Aim.  d.  Phys.  und  Chem.,  1808,  30,  113. 

^  Baumert :      ' '  Chemisclie  Untersuchungen   u.    d.   Respiration    d.   Schlemmpoit- 
gers,"  Breslau,  1885,  24. 

» Jobert:     Ann.  d.  Soc.  Nat.,  1877,  5,  No.  8. 

433 


434  ANESTHESIA 

phenomena  have  long  been  known.  Thu.s,  Panl  Bert/  in  1870  found 
that  if  the  trachea  of  a  kitten  be  clamped  the  animal  will  die  of  asphyxia 
in  about  13  minutes,  but,  if  the  intestine  be  inflated  with  air,  life  may  be 
prolonged  for  21  minutes.  A  similar  absorption  of  oxygen  by  the  in- 
testinal circulation  in  man  is  indicated  by  the  results  of  Tappeiner,^  who, 
in  1886,  on  analysis  of  gases  from  various  portions  of  the  alimentary 
canal  of  an  executed  criminal,  found  in  the  stomach  9.19  per  cent  of 
oxygen,  in  the  ileum  only  a  trace,  and  in  the  colon  and  rectum  none  at 
all,  while  the  percentage  of  carbon  dioxid  showed  a  regular  increase 
from  stomach  to  colon. 

Recognizing  this  activity  of  the  intestinal  mticosa,  the  early  experi- 
menters with  ether  as  an  anesthetic  attempted  its  administration  by  this 
route.  The  method  is  first  mentioned  in  Pirogoff's  ^  work  on  etheriza- 
tion,  published  in  1847.  The  original  idea  of  Pirogoff  was  the  introduc- 
tion of  liquid  ether  into  the  rectum.  Being  warned  by  Magendie  that 
this  could  not  be  done  with  impunity,  he  devised  the  method  of  vaporiz- 
ing the  ether  by  means  of  heat  and  administering  the  drug  in  this  form. 
He  reported  81  cases  with  two  deaths,  but  unfortunately  failed  to  give  a 
detailed  report  of  the  latter.  In  the  same  year,  Eoux,*  y'Yhedo,^  and 
Duprey  *'  employed  injections  of  liquid  ether,  pure  or  in  aqueous  mix- 
ture, with  the  result  of  producing  complete  anesthesia.  Pirogoff,  in  par- 
ticular, wrote  enthusiastically  of  the  advantage  of  the  rectal  method, 
even  expressing  the  belief  that  it  might  supplant  the  inhalation  pro- 
cedure. The  method,  however,  disappeared  from  current  literature,  not 
to  reappear  until  1884.  In  this  year  Molliere  '^  revived  interest  in  the 
subject,  introducing  a  new  technique,  in  which  he  employed  a  Richardson 
hand  bellows  for  forcing  the  ether  vapor  into  the  intestine.  This  method 
he  later  abandoned  in  favor  of  the  earlier  process  of  placing  the 
ether  container  in  a  water  bath  (for  which  he  recommended  a  tem- 
perature of  120°  F.)  and  employing  the  pressure  incident  to  the  genera- 
tion of  vapor  to  force  the  latter  into  the  gut. 

Before  the  close  of  the  year  1884  Yversen,  Hunter,  Bull,®  Weir,^ 
Wancher,^°  and  Post  ^^  had  recorded  their  experience  with  the  method. 

iBert:     Physiol,  compt.  de  la  respir.,  Paris,  1870,  173. 
2Tappeiner:      Arheiten  a.   d.   path.  Institut  su  Miinchen,    1886. 
3  Pirogoff :     ' '  Eecherches  pratiques  et  physiologiques  sur  1  'etherization, ' '  St. 
Petersburg,  1847. 

4Roux:     J.  d.  I'academie  d.   Sciences,  1847,  18. 

5  Y  'Yhedo :     Gazette  med.  d.  Paris,  1847. 

6  Duprey:      Academic  royale  de  medecine,  March   16,   1847. 

7  Molliere:     Lyon  medical,  45,  1884. 

8  Bull:      N.  Y.  Med.  J.,  March  3,   1884. 

9  Weir:     Med.  Rec,  1884. 

10  Waneher :     Cong,  internat.  d.  sciences  med.,  1884. 

11  Post :     Boston  Med.  and  Surg.  J.,  1884. 


ANESTHESIA  BY  COLONIC  ABSORPTION   OF   ETHER      435 

Among  these  cases  a  number  showed  more  or  less  marked  diarrhea  and 
melena  and  one  death  was  directly  traceable  to  the  procedure. 

The  method  again  fell  into  disuse,  not  to  be  revived  until  1903,  when 
Cunningham  added  to  the  technique  of  administration  a  new  feature 
in  the  employment  of  air  as  a  vehicle  for  carrying  the  ether  vapor  into 
the  intestine.  The  first  publication  of  Cunningham  (written  jointly 
with  Leahy  ^)  appeared  in  1905,  being  preceded  by  articles  by  Dumont,^ 
and  Krugeline,^  the  latter  reporting  43  cases  without  untoward  symp- 
toms. 

Stimulated  by  the  records  of  improved  results  following  the  use  of 
the  Cunningham  technique,  many  surgeons  and  anesthetists  hastened  to 
give  the  method  a  new  trial,  with  the  result  that  the  subject  has  now 
acquired  a  considerable  literature. 

In  1906  Stucky  *  reported  4  cases  with  favorable  comment  on  the 
utility  of  the  method.  In  the  same  year,  Lumbard  ^  reported  four  lapa- 
rotomies done  under  this  method  of  anesthesia. 

Buxton,^  in  the  1907  edition  of  his  "Angesthetics,"  in  speaking  of 
'^rectal  etherization,"  says :  "I  have  now  used  the  method  pretty  exten- 
sively, and  find  it  to  answer  admirably  for  operations  about  the  mouth, 
nose,  and  post-buccal  cavities,  for  intra-  and  extralaryngeal  operations, 
for  staphylorrhaphy,  and  for  operations  for  the  relief  of  empyema.  For 
the  removal  of  the  tongue,  for  excision  of  the  jaw,  or  jaws,  and  for 
plastic  operations  about  the  face,  the  method  gives  greater  facilities  and 
freedom  to  the  operator  than  any  other  plan  I  have  tried.  Mr.  Appleby 
recommends  the  method  also  for  prolonged  dental  operations." 

Buxton  gives  no  figures  on  number  of  cases  or  number  of  disadvan- 
tageous results.  Of  the  latter  he  says :  "I  have  met  with  grave  compli- 
cations, which,  although  in  part  due  to  the  physical  condition  of  the  pa- 
tients, were  undoubtedly  not  wholly  independent  of  irritation  caused  in 
the  intestines  by  the  entrance  of  ether  vapor."  In  a  paragraph  on 
after-effects  he  says :  "Colicky  pains  in  the  intestines,  urgent  tenesmus, 
diarrhea  sometimes  dysenteric  in  character,  painful  distention  of  the 
intestinal  tract  with  more  or  less  severe  collapse,  are  complications 
which  have  been  recorded.  Deaths  have  occurred."  Unfortunately  he 
does  not  state  which  of  these  have  occurred  in  his  own  skillful  hands. 
His  method  is  practically  identical  with  that  advocated  by  Pirogoff,  i.  e., 
the  generation  of  ether  vapor  by  heat  and  its  direct  conveyance  under  its 
own  power  to  the  intestines. 

^Cunningham  and  Leahy:      Boston  Med.  and  Surg.  J.,   April  20,  1905. 

^Dumont:     Correspond.-Bl.  f.  schweitzer  Aertse,  1903;  ibid.,  1904;  ibid.,  1908. 

'  Krugeline :      Wiener  Jclin.   Woch.,  Dec,   1904. 

*  Stucky:     J.  Am.  Med.  Assn.,  July  28,  1906. 

'Lumbard:     Med.  Bee,  Dec.  1,  1906. 

°  Buxton:      "Anaesthetics,"   London,    1907. 


436  ANESTHESIA 

An  intercepter  is  used  to  prevent  passage  of  liquid  ether  into  the  gut, 
and  a  temperature  of  not  higher  than  120°  F.  is  recommended  for  the 
water  bath  in  which  the  ether  container  is  immersed. 

Leggett/  in  1907,  reported  a  series  of  animal  experiments  and  13 
personally  conducted  cases,  which  in  the  main  gave  satisfactory  results. 
Leggett  added  to  the  Cunningham  apparatus  an  outlet  communicating 
with  the  vapor-carrying  tube  by  a  branched  connection.  This  facilitated 
the  relief  at  any  time  of  intra-intestinal  pressure. 

Dumont,^  in  1908,  reported  4  cases,  in  all  of  which  a  smooth  and 
satisfactory  narcosis  was  maintained,  practically  without  undesirable 
after-effects.  The  apparatus  was  a  modification  of  that  described  by 
Dudley  Buxton.  Though  commending  it  highly  for  suitable  cases,  Du- 
mont  justly  warns  his  readers  that  it  is  a  method  for  exceptional  cases; 
that  it  should  be  used  only  on  properly  prepared  patients  without  intes- 
tinal lesions,  and  only  by  a  skillful  administrator. 

In  the  same  year  Anna  Morosow  ^  reported  from  the  clinic  of  Pro- 
fessor A.  Kadhan  at  St.  Petersburg  a  series  of  68  head  and  neck  cases. 
Of  these,  61  slept  smoothly;  in  5  narcosis  was  incomplete;  in  2  surgical 
anesthesia  could  not  be  attained.  The  duration  of  anesthesia  varied  from 
10  minutes  to  2  hours  and  45  minutes.  Anesthesia  was  first  induced  by 
inhalation,  and  then  maintained  by  the  rectal  method.  The  average  con- 
sumption of  ether  for  the  induction  and  maintenance  of  anesthesia  to- 
gether was  1.2  grams  per  minute;  that  for  the  period  during  which  the 
rectal  method  was  used  0.6  gram. 

Morosow  observed  that  awakening  was  very  prompt.  Bloody  diarrhea 
occurred  in  1  case,  blood-streaked  stool  in  5,  abdominal  pain  in  3  cases, 
vomiting  during  narcosis  in  3  cases. 

The  apparatus  used  was  essentially  that  of  Pirogoff  and  Buxton,  a 
temperature  of  50°  C.  being  recommended  for  the  water  bath. 

In  1909  Denny  and  Eobinson  *  recorded  a  series  of  10  cases  with 
gratifying  results.  In  this  year  also  Baum  °  reported  8  cases  anes- 
thetized with  the  apparatus  of  Pirogoff.  Three  cases  showed  ideal  anes- 
thesia, 2  cases  were  restless,  in  1  (an  operation  for  epigastric  hernia) 
distention  greatly  hindered  the  operator,  and  the  patient  became  anes- 
thetized to  a  dangerous  degree.  In  2  other  cases  unfortunate  after- 
results  were  observed.  Both  complained  of  abdominal  pain  during  the 
induction  of  anesthesia,  which  lasted  unusually  long,  and  both  showed 
marked  abdominal  distention.  The  first  suffered  after  operation  from 
profuse  hemorrhage  from  the  bowels  (680  c.  c.  in  48  hours),  while  the 

*  Leggett:     Ann.  Surg.,  Oct.,  1907. 
='Dumoiit:      Ibid.,  1908. 

'Morosow:      Buss.  ArcMv  f.  Chir.,  1908. 

*  Denny  and  Eobinson :     J.  of  Minn.  Med.  Assn.,  Feb.  1,  1909. 
=  Baum:     Zeit.  f.  Chir.,  1909,  No.  II. 


ANESTHESIA  BY  COLONIC  ABSORPTION  OF   ETHER      437 

second  died  the  morning  after  the  operation  and  revealed  at  autopsy  a 
gangrenous  and  perforated  cecum  and  general  peritonitis. 

Carson/  in  1909,  reported  a  series  of  18  cases,  2  of  which  were  un- 
successful because  of  incomplete  preparation.  One  of  the  remaining  16 
cases,  a  large  and  muscular  man  who  was  delirious  at  the  time,  could 
not  be  anesthetized  without  the  aid  of  a  mask,  which  was  used  through- 
out the  operation.  One  case  had  slight  bleeding  from  the  rectum. 
There  were  2  deaths  (an  extensive  face  carcinoma,  and  a  case  of  extreme 
hyperthyroidism).     The  author's  apparatus  was  used. 

In  July,  1909,  Legueu,  Morel  and  Yerliac  ^  reported  a  series  of  ex- 
perimental cases,  and  expressed  the  belief  that  proper  administration  by 
this  method  is  no  more  dangerous  than  that  by  inhalation.  Oxygen  was 
used  as  a  vehicle  for  the  ether-vapor,  which  was  allowed  to  form  at  room 
temperature. 

In  1910  Sutton  ^  published  the  results  of  a  series  of  about  140  per- 
sonally conducted  cases  together  with  a  description  of  the  apparatus  de- 
veloped in  the  course  of  the  work  and  the  technique  used  in  the  applica- 
tion of  the  method  at  Eoosevelt  Hospital. 

About  the  same  time,  J.  H.  Cunningham,  Jr.,*  published  his  third 
article  on  the  subject,  giving  the  best  review  of  the  literature  that  had 
appeared  up  to  this  time. 

Shortly  after  this  Thomas  ^  published  a  description  of  an  apparatus 
for  rectal  and  pharyngeal  anesthesia,  which  corresponds  in  principle  al- 
most detail  for  detail  with  that  described  by  Sutton  (10  op.  cit.).  This 
author,  however,  provides  for  a  continuous,  or  almost  continuous,  return 
flow  of  the  ether-laden  vehicle,  somewhat  after  the  manner  described  by 
Vidal  ^  in  1906.  The  article  deals  exclusively  with  a  description  of  the 
apparatus  and  direction  for  its  use,  making  no  reference  to  specific  cases 
or  to  after-results.    There  are  no  citations  to  the  literature. 

In  August,  1910,  Churchill  ^  reported  47  cases  anesthetized  with  the 
apparatus  of  Leggett.  The  range  of  age  was  from  6  months  to  73  years. 
The  time  of  anesthesia  varied  from  10  minutes  to  2  hours,  and  narcosis 
was  satisfactory  to  the  operator  in  all  but  7  cases.  Two  of  these  were 
herniotomies,  in  which  anesthesia  was  complete,  but  in  which  the  opera- 
tor was  embarrassed  by  abdominal  distention.  Five  could  not  be  fully 
anesthetized — four  because  of  insufficient  preparation,  one  because  of  a 
leak  in  the  apparatus.  Alcoholic  patients  seemed  to  be  more  easily  nar- 
cotized by  this  than  by  the  inhalation  method.    Disturbance  in  the  colon 

^Carson:     Interstate  Med.  J.,  Nov.  5,  1909,  16. 

^Legue.u,  Morel  and  Verliac:      Compt.  rendu  Soc.   iiol.,  June- July,  1909. 

"Sutton:     Ann.  Surg.,  April,  1910. 

*  Cunningham:     N.  ¥.  Med.  J.,  April  30,  1910. 
''Thomas:      Tale  Med.  J.,  May,   1910. 

*  Vidal:     Presse  medicale,  14,  1906. 
'Churchill:     Surg.  Gynec.  and  Ohstet.,  1910,  11,  2. 


438 


ANESTHESIA 


was  observed  in  but  one  case,  and  only  in  the  form  of  slight  pain  and 
blood  in  the  stool  18  hours  after  operation  on  a  patient  who  suffered  be- 


FiG.  167. — Latest  Form  of  Colonic  Anesthesia  Apparatus,  a,  Water  jacket  for 
vaporizing  chamber;  b,  Drip  cock  for  water  jacket;  c,  Vaporizing  chamber;  d,  Ther- 
mometer suspended  in  water  jacket  by  metal  clip;  e,  Metal  tube  carrying  oxygen  to 
spiral  wier;  f,  Spiral  wier;  g,  Chamber  in  water  jacket  for  tubular  heating-bulb;  h, 
4-way  cock  permitting  administration  of  pure  oxygen  or  oxygen-ether  mixture;  i, 
Outlet  tube  for  ether-oxygen  mixture;  j,  Afferent  tube  to  colon;  k,  Tube  connecting 
4-way  cock  with  spiral  wier;  1,  Tube  from  oxygen  tank  to  4-way  cock;  m,  Glass  tube 
forming  terminus  of  efferent  tube  from  colon;  this  tube  is  sealed  only  by  immersion  in 
water  of  cylinder  "o";  n,  Efferent  tube  from  colon;  o,  Water  manometer  cylinder; 
the  amount  of  pressure  in  the  colon  is  determined  by  the  depth  to  which  the  tube 
"m"  is  immersed;  p,  Oxygen  tank;  q,  Carrying  stand;  r,  Y-tube  connecting  rectal 
tube  with  afferent  and  efferent  tubes;  s,  Short  rectal  tube  with  sphincter-bulb  and 
multiple  fenestrse. 


fore   with    hemorrhoids.      Post-anesthetic    nausea    and    vomiting    were 
greatly  reduced. 

Sanders/  in  August,   1910,  reported  11   cases.     In  1,  inefficiently 
prepared,  the  rectal  tube  became  plugged  after  a  half  hour  of  satisfactory 
^Sanders:     Homeopath.  Eye,  Ear  and  Throat  J.,  Aug.  1910. 


ANESTHESIA  BY  COLONIC   ABSORPTION   OF   ETHER      439 

anesthesia,  necessitating  resort  to  inhalation.  In  1  staphylorrhaphy,  chlo- 
roform was  required  by  mouth  during  part  of  the  operation.  In  several 
others  momentary  whiffs  of  chloroform  were  needed,  and  to  supply  this 
need  Sanders  added  to  Sutton's  simple  form  of  apparatus  a  Junker  vial 
immersed  in  the  same  water  with  the  ether  container  and  receiving  its 
supply  of  air  from  the  same  bulb  as  the  latter. 

The  Physiology  of  Colonic  Anesthesia. — Theoretically  the  adminis- 
tration of  any  anesthetic  should  presuppose  a  full  knowledge  on  the  part 
of  the  anesthetist  of  the  physiological  action  of  the  drug.  Practically, 
however,  in  case  of  pulmonary  anesthesia,  this  knowledge  may  be,  and, 
in  the  vast  majority  of  cases,  is  dispensed  with  in  favor  of  an  accurate 
knowledge  of  the  symptoms  of  incomplete  and  of  excessive  narcosis,  and 
of  the  practical  means  of  correcting  each.  This  knowledge,  gained  by 
extensive  observation  and  supervised  experience  in  the  pulmonary  method 
of  administration,  is  not  sufficient  basis  for  the  undertaking  of  adminis- 
tration by  the  colonic  method. 

In  the  pulmonary  method  the  drug  is  taken  in  by  the  automatic 
respiratory  efforts  of  the  patient,  and  is  eliminated  in  the  same  way  if 
pure  air  be  substituted  for  the  anesthetic  mixture.  No  anesthetic-con- 
taining reservoir  remains  to  continue  imparting  the  drug  to  the  blood 
plasma.  Further,  as  the  only  means  of  elimination  of  the  anesthetic 
is  the  same  as  the  means  of  absorbing  it,  only  so  great  an  amount  of  the 
drug  need  be  absorbed  as  is  necessary  to  produce  in  the  general  circula- 
tion the  required  14  of  1  psr  cent  for  the  narcotization  of  the  central 
nervous  system  (cf.  Overton  ^).  The  absorbing  surface  of  the  lungs  is  so 
great  and  so  well  adapted  to  the  purpose  that  a  comparatively  low  con- 
centration of  anesthetic  vapor  in  the  respired  air  is  sufficient  to  produce 
the  required  percentage  in  the  circulating  blood. 

In  the  colonic  method  of  administration  all  these  conditions  are 
changed.  The  drug  cannot  be  taken  in  by  the  muscular  action  of  the 
patient,  nor  can  any  unabsorbed  excess  be  directly  eliminated  in  that 
way.  In  the  case  of  over-deep  narcosis  the  unabsorbed  residue  of  the 
drug  must  be  evacuated  by  the  active  intervention  of  the  operator. 
There  must  be  considered  in  the  use  of  this  method  the  fact  that  the 
blood,  after  leaving  the  intestine  with  its  load  of  ether,  is  obliged  to  pass 
through  the  lungs  before  reaching  its  goal  in  the  central  nervous  system, 
and  that  in  so  doing  a  considerable  portion  of  the  contained  ether  will  be 
eliminated  into  the  air.  The  concentration  of  the  drug  at  the  ]Doint 
of  absorption,  therefore,  may  not  be  I/4  of  1  per  cent  of  the  pulmonary 
method,  but  1/4  per  cent  plus  the  percentage  necessarily  lost  by  exhala- 
tion. Again,  the  absorbing  surface  of  the  colon  is  much  smaller  than 
that  of  the  lungs,  and  the  arrangement  of  the  vessels  j)erhaps  less  favora- 
ble to  gaseous  interchange,  so  that  a  higher  concentration  is  required. 

^Overton:     Studien  u.  d.  Narlcose,  1901,  185. 


440  ANESTHESIA 

Each  of  these  differences  requires  the  intelligent  attention  of  the 
anesthetist.  Since  the  anesthetic  mixture  must  be  forced  into  the  intes- 
tine, one  is  immediately  confronted  with  the  question  of  the  proper  de- 
gree of  pressure  to  be  used  in  the  process.  A  sufficient  degree  must  be 
employed  to  obtain  moderate  distention  of  the  entire  colon,  else  the  avail- 
able absorbing  surface  will  be  too  small.  Too  much  pressure  must  not 
be  exerted  lest  by  overdistention  the  vessels  of  the  gut  be  flattened  out, 
circulation  impeded  or  abolished,  and  absorption  minimized,  and  the 
ischemic  mucosa  be  left  unprotected  by  its  normal  circulation  to  resist 
the  irritant  effects  of  the  ether  vapor.  The  contention  may  be  raised 
that  experiments  in  which  narcosis  has  been  produced  by  the  use  of  high 
pressure  are  sufficient  to  disprove  this  statement.  The  error  in  this  con- 
tention arises  from  the  fact  that  excessive  pressure  breaks  down  the  re- 
sistance of  the  ileocecal  valve,  as  observed  by  Leggett  on  dogs,  and  by 
Lumbard  ^  in  the  human  subject,  and  that  the  narcosis  is  obtained  by 
absorption  under  diminished  pressure  from  the  coils  of  the  small  intes- 
tine.^ 

The  writer's  attention  was  first  directed  to  the  necessity  for  the  use 
of  a  moderate  pressure  by  the  repeated  observation  that  reduction  of 
pressure  often  resulted  in  deepening  of  the  narcosis. 

The  optimum  pressure  to  be  maintained  in  the  colon  has  been  deter- 
mined experimentally  to  be  about  20  mm.  of  mercury,  which  is  approxi- 
mately equal  to  the  sum  of  the  positive  pressure  in  the  intestinal  capil- 
laries, and  the  negative  pressure  in  the  portal  vein.  This  would  be  varied 
according  to  the  blood  pressure  of  the  patient,  i.  e.,  should  be  reduced  to 
10  or  12  mm.  in  young  children  and  may  be  increased  in  individuals  with 
abnormally  high  blood  pressure.^ 

On  account  of  the  inevitable  loss  of  ether  from  the  blood  in  its  pas- 
sage through  the  lungs,  it  is  sometimes  necessary  to  adopt  means,  to  be 
mentioned  later,  for  keeping  the  respired  air  more  or  less  laden  with 
ether.  For  the  same  reason,  because  of  the  smaller  and  less  efficient  ab- 
sorbing area  of  the  colon  as  compared  with  that  of  the  lung,  a  relatively 
high  concentration  of  the  anesthetic  mixture  may  be  used.    To  meet  this 

^Lumbard:     Med.  Eec,  Dec.  1,  1906. 

^  In  connection  with  this  point  it  is  important  for  those  who  make  use  of  the 
colonic  method  of  etherization  to  watch  for  symptoms  of  the  so-called  ' '  delayed 
ether  poisoning"  since  from  the  foregoing  it  is  plain  that  the  liver — the  great 
sufferer  in  this  condition — is  treated  to  a  higher  concentration  of  ether  than  in 
the  same  grade  of  narcosis  from  pulmonary  administration.  No  case  of  thi9 
kind  has  come  to  the  writer's  attention,  however,  unless  the  peculiar  death  men- 
tioned on  page  455  has  some  affiliation  with  this  class  of  cases. 

"  In  connection  with  this  question  it  is  well  to  have  in  mind  the  experiments 
of  Quirin,  in  one  of  which  a  normal  healthy  cat  having  a  blood  pressure  of  85 
mm.  died  after  5  minutes  of  an  intra-abdominal  pressure  of  10  mm.  Deutsch. 
Arch.  f.  Uin.  Med.,  1901,  21,  79. 


ANESTHESIA  BY  COLONIC  ABSORPTION   OF   ETHER      441 


last  requirement,  a  number  of  early  investigators  and,  unfortunately, 
some  recent  ones  adopted  the  expedient  of  passing  pure  ether  vapor 
into  the  gut  under  the  pressure  incident  to  its  generation.  This  doubly 
dangerous  procedure  has  resulted  in  a  number  of  deaths,  in  one  of  which 
(reported  by  Professor  Baum)  autopsy  showed  a  gangrenous  and  per- 
forated cecum  and  general  suppurative  peritonitis. 

The  danger  of  too  great  concentration  of  ether  is  obviated  in  the 
method  used  by  Sutton,  by  employing  oxygen  (or  air)  as  a  vehicle  and 
by  keeping  the  ether  from  which  the  vapor  is  derived  well  below  its  boil- 
ing point.    By  maintain- 
ing a  uniform  tempera- 
ture in  the  ether,  with  a 
fairly    constant    flow    of 
oxygen    and    a    definite 
period  of   association  of 
the  oxygen  stream  with 
the  liquid  ether,  a  fairly 
constant  degree  may  be 
attained. 

Development  of  the 
Method. — From  the  con- 
siderations Just  reviewed 
it  is  apparent  that  the 
history  of  the  develop- 
ment of  this  method  of 
ether  administration  is 
intimately  associated 
with  that  of  the  develop- 
ment of  the  apparatus  employed.  Pirogoff  used  an  ether  container  im- 
mersed in  a  water  bath  at  a  temperature  of  120°  P.,  with  a  rubber  tube 
to  lead  the  pure  ether  vapor  into  the  rectum.  An  almost  exactly  similar 
apparatus  was  used  by  Buxton,  Baum,  Dumont,  Kadjan,  and  Morosow 
(Fig.  168),  as  well  as  in  the  cases  reported  by  Bull,  Weir,  and  Post. 

Cunningham,  of  Boston,  made  the  first  great  advance  by  using  a 
water  bath  of  a  temperature  below  the  boiling  point  of  ether,  and  by  car- 
rying the  vapor  of  the  latter  into  the  intestine  in  a  vehicle  of  air.  (Mol- 
liere  had  previously  used  a  hand  bellows  to  force  the  ether  vapor  into 
the  intestine,  but  ^dthout  admixture  of  the  air.)  In  the  Cunningham 
apparatus  no  provision  was  made  for  emptying  the  distended  intestine, 
this  being  accomplished  when  necessary  by  inserting  the  finger  of  the 
anesthetist  through  the  sphincter  ani  alongside  the  rectal  tube. 

Vidal  added  to  the  apparatus  a  provision  for  a  continuous  return 
flow  of  gas  from  the  rectum,  and  a  year  later  Leggett  added  to  the  Cun- 
ningham apparatus  an  exhaust  tube  which  could  be  opened  when  it  was 


Fig.   168. 


-Apparatus  for  Administering  Ether 
PER  Rectum.     (Buxton.) 


442 


ANESTHESIA 


desired  to  empty  the  intestine,  but  which  remained  closed  in  the  interval. 

In  July,  1909,  Ligueu,  Morel,  and  Verliac  (Fig.  169)  first  reported 
the  use  of  oxygen  as  a  vehicle  for  ether  vapor  ^  in  rectal  anesthesia.  The 
work  of  these  writers  was  confined  to  animal  experimentations. 

The  apparatus  (Fig.  170)  of  Leggett  represented  the  "state  of  the 
art"  at  the  beginning  of  Sutton's  series  of  cases,  and,  with  the  exception 


Fig.  169. — Appahatus  of  Ligueu,  Morel  and  Vbhliac. 

of  the  U  tubes,  was  essentially  the  apparatus  used  in  the  earlier  work. 
In  a  number  of  these  cases  it  gave  entirely  satisfactory  results ;  in  others, 
obstacles  were  encountered  which  made  difficult,  or  even  prevented  en- 
tirely, the  attainment  of  satisfactory  surgical  narcosis.     The  study  of 


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Fig.  170. — Leggett's  Appabatus. 

each  of  these  difficulties  has  resulted  in  some  modification  of,  or  addition 
to,  the  apparatus. 

Thus  it  frequently  happened  that  semi-solid  fecal  matter,  escaping 

^  Sutton  had  independently  used  oxygen  in  this  capacity  in  etherization  of  a 
human  subject  as  early  as  Nov.,  1907. 


ANESTHESIA  BY  COLONIC  ABSORPTION   OF   ETIiER      443 

vs'ith  the  gas  on  opening  the  exhaust  tube,  became  lodged  in  the  tubing, 
and  prevented  the  free  passage  of  gas  in  either  direction.  To  prevent 
this,  a  special  form  of  tube  was  made  and  arranged  to  stand  between  the 
patient's  thighs  close  to  the  anus  in  such  a  position  that  any  fluid  or 
semi-solid  matter  passing  in  either  direction  would  drop  down  into  the 
branch  of  the  tube  leading  to  the  exhaust.  The  caliber  of  the  entire  ex- 
haust tube  was  made  considerably  greater  than  that  used  for  carrying 
the  ether  vapor  to  the  intestine.  To  meet  the  changed  condition  brought 
about  by  the  new  position  of  the  branch  tube,  the  rectal  tube  was  short- 
ened to  about  8  inches  in  length;  and,  since  the  one  or  two  eyes  of  the 
ordinary  rectal  tube  frequently  became  closed  by  prolapse  of  rectal  mu- 
cosa, or  by  the  lodgment  of  fecal  matter,  tubes  having  from  5  to  7  eyes 
have  been  adopted.  On  account  of  the  frequency  of  leakage  around  the 
rectal  tube,  preventing  the  maintenance  of  sufficient  pressure  to  inflate 
the  gut,  a  bulb  from  %  to  1  inch  in  diameter  has  been  made  on  the  tube 
at  a  point  which  in  use  lies  just  inside  the  sphincter.  Another  accident 
which  at  times  prevented  the  free  passage  of  gases  was  the  weight  of  the 
patient's  thigh  on  the  flexible  afferent  and  efferent  tubes. ^  This  difficulty 
was  met  by  winding  the  exposed  portion  of  the  tubing  with  steel  wire,  or 
by  the  substitution  of  tubing  having  a  very  heavy  wall. 

The  observation  that  in  some  cases  a  diminution  of  gas  pressure  in 
the  gut  resulted  in  a  deepening  of  the  narcosis  led  to  recognition  of  the 
fact  that  too  great  pressure  produces  ischemia  of  the  gut  and  conse- 
quent interruption  of  absorption.  To  guard  against  this  incident  a  mer- 
cury manometer  was  added  to  the  apparatus,  so  that  the  pressure  of  the 
gas  in  the  gut  might  always  be  kept  below  that  of  the  blood  in  the  intes- 
tinal capillaries.  For  the  more  easy  recognition  of  the  escape  of  gas  on 
opening  the  exhaust,  the  distal  end  of  the  latter  was  immersed  in  a 
bottle  of  water  placed  under  the  operating  table;  and,  to  prevent  con- 
fusion as  to  whether  the  gas  there  seen  or  heard  to  escape  is  coming 
from  the  gut  or  from  the  generator,  a  combination  clip  was  devised 
which  necessitates  the  closure  of  the  afferent  tube  before  the  efferent 
tube  can  be  opened. 

Inasmuch  as  it  has  sometimes  been  necessary,  as  will  be  explained 
later,  to  administer  a  certain  amount  of  anesthetic  by  mouth  as  a  sup- 
plement to  the  quantity  absorbed  by  the  intestine,  a  tube  has  been  pro- 
vided, by  means  of  which  ether  vapor  can  be  diverted  from  the  main 
afferent  tube  and  allowed  to  escape  into  the  mouth  or  nose  of  the  pa- 
tient. Finally,  on  account  of  the  instability  of  the  cylinder  form  of 
ether  generator  and  of  the  more  and  more  frequent  use  of  oxygen  as  a 
vehicle  for  the  ether  vapor,  a  compact  metal  generator  has  been  devised, 

^  These  terms  are  not  used  in  the  sense  in  which  they  are  employed  by  Cun- 
ningham as  afferent  and  efferent  to  the  vapor  generator,  but  as  afferent  and 
efferent  to  the  patient. 


444  ANESTHESIA 

which,  though  no  more  efficient  in  maintaining  narcosis  than  the  cylin- 
der form,  presents  a  number  of  advantages  which  willbe  detailed  later. 

Sanders  has  since  modified  the  simpler  form  of  this  apparatus  by 
adding  a  chloroform  vapor  generator  which,  when  immersed  in  the  same 
water  bath  as  the  ether  container,  serves  to  meet  the  occasional  require- 
ment for  accessory  inhalation  anesthesia.  Thomas  has  also  produced  an 
apparatus,  which,  though  differing  from  it  in  detail,  meets  the  same  re- 
quirements as  that  of  Sutton.  In  it  he  uses  as  a  matter  of  routine  the 
safety-valve  water  manometer  recommended  by  Sutton  for  use  in  mouth 
and  throat  cases. 

Sutton's  Apparatus. — The  original  apparatus  in  use  at  Eoosevelt 
Hospital  was  that  of  Cunningham — the  simplest  possible  means  of  forc- 
ing air  through  warmed  ether  and  carrying  the  ■  mixture  into  the  intes- 
tines— plus  a  branch  tube  used  for  exhausting  the  contents  of  the  gut 
when  occasion  required.  The  latter  feature,  introduced  by  Leggett,  is 
one  of  the  valuable  points  in  the  apparatus  with  which  this  section  is 
concerned. 

The  complete  apparatus  may  be  regarded  as  consisting  of  three  parts : 

(1)  A  generator  in  which  the  mixture  of  oxygen  and  ether  is  produced; 

(2)  an  afferent  tube  system  which  carries  this  product  into  the  intes- 
tine; and  (3)  an  efferent  tube  system  for  the  purpose  of  exhausting  the 
contents  of  the  gut. 

The  Generator. — This  portion  of  the  apparatus  consists  of  a  small 
generating  chamber  surrounded  by  a  water  jacket  and  connected  with 
an  ether  storage  chamber,  which  automatically  maintains  a  given  level 
of  ether  in  the  generating  chamber.  The  arrangement  and  working  of 
the  various  parts  will  be  most  readily  understood  by  a  glance  at  the  pho- 
tograph of  the  dissected  apparatus  (Fig.  171)  and  the  schematic  sag- 
ittal section  shown  in  Fig.  173. 

Only  one  feature  will  require  special  description.  This  is  the  spiral 
wire  1,  which  determines  the  prolonged  intimate  contact  of  the  oxygen 
(or  air)  with  the  fluid  ether.  This  device  consists  of  a  spirally  wound 
strip  of  thin  brass  %  of  an  inch  wide  and  about  14  inches  in  length, 
soldered  to  the  bottom  of  the  circular  disk  h,  with  which  the  oxygen 
inlet  tube  a  connects. 

The  level  of  the  ether  in  the  generating  chamber  is  automatically 
maintained  at  such  a  height  as  just  to  cover  this  wire  and  disk.  The 
oxygen  (or  air)  is  admitted  to  the  apparatus  through  the  tube  a,  emerges 
below  the  level  of  the  ether  under  the  plate  Tc,  and  finds  its  way  to  the 
surface  only  after  traversing  all  the  windings  of  the  spiral.  This  neces- 
sitates intimate  association  of  oxygen  with  ether  for  a  distance  of  14 
inches,  and  has  been  shown  experimentally  to  bring  about  a  complete 
saturation  of  the  former  with  the  latter. 

The  ether-saturated  oxygen  rises  into  the  upper  part  of  the  generat- 


Fig.  171. — Parts  of  Vapor  Generator,  a,  Oxygen  (or  air)  inlet;  b,  connection  to 
afferent  tube  system;  c,  by-pass  for  inflating  intestine  with  pure  oxygen  (or  air) ;  d,  clip 
■  for  closing  by-pass;  e,  H-tube  connecting  oxygen  tank  and  air  bulb  with  generator 
and  by-pass;  f,  connection  of  H-tube  with  air  bulb;  g,  connection  of  H-tube  with 
oxygen  tank;  k,  disc  forming  top  of  spiral  wier;  1,  spiral  wier;  m,  manometer;  n,  ther- 
mometer projecting  out  of  water-jacket;  r,  tubular  incandescent  bulb  for  heating 
water-jacket;  s,  ether  reservoir;  t,  ether  can  inverted  in  reservoir;  with  upper  part  of 
generating  chamber;  w,  glass  tube  connecting  ether  reservoir  with  generating  chamber 
below  level  of  ether;  x,  flattened  spike  for  perforating  seal. of  ether  can;  g',  metal  brace 
between  reservoir  and  generating  chamber;  z,  cover  over  hole  for  filling  water-jacket; 
zz,  cover  of  generating  chamber. 


Fig.   172. — Schematic  Section  of  Vapor  Generator. 


446 


ANESTHESIA 


ing  chamber,  and  is  carried  by  the  tube  h  into  the  afferent  tube  leading 
to  the  intestine.  The  main  body  of  the  ether  remains  in  the  original 
package  t,  which  is  inverted  in  the  ether  reservoir  s.     To  charge  the 


.^? 


generator,  a  sealed  ether  can  (this  ap- 
paratus is  designed  to  take  a  Squibb's 
259-gram  can)  is  inverted  in  the  reser- 
voir, the  seal  being  penetrated  in  the 
act  by  a  flattened  spike  x,  which  pro- 
jects from  the  bottom  of  the  reservoir. 
A  twist  of  the  can  serves  to  ream  out 
a  fair-sized  opening.  Ether  then  flows 
out  into  the  lower  part  of  the  reservoir 
and  into  the  generating  chamber  until 
it  has  reached  a  level  above  the  perfora- 
tion in  the  seal,  when,  the  entrance  of 
air  being  interrupted,  the  outflow  of 
ether  ceases  until  the  level  of  the  fluid 
has  been  again  reduced,  to  allow  more 
air  to  bubble  up  into  the  dome  of  the 
ether  can.  Before  any  pressure  is  put 
on  the  generating  chamber,  the  cover  u 
of  the  ether  reservoir  must  be  screwed 
on  air  tight. 

Surrounding  the  generating  cham- 
ber is  the  water  jacket  o,  which  is  main- 
tained at  a  temperature  of  88°  to  90° 
F.  (not  higher)  by  the  10  candle  power 
tubular  incandescent  electric  lamp  r 
inserted  into  the  blind  tube  q.  A  ther- 
mometer, n,  projecting  from  the  top  of 
the  water  jacket,  readily  shows  the 
temperature  of  the  contained  water.  A 
manometer  m  projects  from  the  cover 
zz  of  the  generating  chamber,  and 
hence  determines  the  pressure  in  the 
intestine  of  the  patient.  This  manom- 
eter, of  which  a  sectional  drawing  is 
shown  in  Fig.  173,  also  serves  the  pur- 
pose of  a  safety  valve,  being  so  con- 
structed that,  when  the  pressure  reaches  a  point  a  few  millimeters  above 
the  maximum,  the  oxygen-ether  mixture  of  the  generating  chamber  is 
permitted  to  bubble  up  through  the  mercury  and  to  escape  into  the  air. 
This  point  is  of  importance,  since  the  needle  valve  of  the  oxygen  tank 
may  be  accidentally  opened  too  wide,  which,  in  the  absence  of  such  a 


Fig.  173. — Sectional  View  of  Ma- 
nometer, mc,  mercury  column; 
pi,  pressure  inlet;  cp,  cotton  plug 
in  pressure  vent;  eg,  cover  of  gen- 
erating chamber;  rt,  short  piece  of 
rubber  tube  connecting  manometer 
with  cover. 


Y,,iiM,iir^>mijj,ji.JiJJJ/Jl^,J>^'->'JJJ^^-''-'-'J---^'ZZ 


ANESTHESIA  BY  COLONIC  ABSORPTION  OF   ETHER      447 

safety  valve,  would  put  a  dangerous  pressure  on  the  gut.  When  such 
excessive  pressure  has  subsided,  the  mercury  falls  back  from  the  upper 
chamber  of  the  manometer,  and  the  safety  valve  is  closed. 

The  H-tube  e  makes  it  possible  to  have,  at  the  same  time,  means  of 
passing  either  oxygen  or 
air  through  the  genera- 
tor and  also  of  inflating 
the  intestine  with  pure 
oxygen  or  air  without 
appreciable  admixture 
of  ether.  This  latter 
procedure  is  accom- 
plished by  simply  open- 
ing the  pressure  clip  d, 

which  allows  the  oxygen  or  air  to  pass  into  the  afferent  tube  and  on  into 
the  intestine  without  making  its  way  through  the  generator  itself.  The 
generator  may  be  hung  by  a  bracket  from  the  oxygen  tank,  as  shown  in 
Figure  176,  or  set  upon  a  small  table. 

For  those  who  wish  to  make  their  own  apparatus,  a  simpler  form  of 


Fig.  174. — Sectional  View  of  H-Tube.  ac,  afferent 
connection;  ec,  efferent  connection;  rtc,  rectal  tube 
connection;  br,  brace. 


\^^.  ipaSS 


Fig.  175. — Simple  Form  of  Sutton's  Apparatus.     Manometer  not  shown. 


generator  will  be  found  quite  satisfactory.  This  may  be  made  by  the  use 
of  the  spiral  wire  in  any  wide-mouthed  bottle  capable  of  containing  250 
to  400  grams  of  ether  and  4  or  5  inches  of  free  space  between  the  fluid 
and  the  cork.  The  manometer  is  inserted  through  the  cork  and  the 
proper  afferent  connections  provided.  In  the  place  of  the  water  jacket, 
a  pail  of  warm  water  is  provided,  and  the  bottle  partly  immersed  in  it. 
The  temperature  is  registered  by  a  floating  thermometer,  and  is  kept 


ANESTHESIA  BY  COLONIC  ABSORPTION  OF   ETHER      449 

up  to  the  proper  point  by  occasional  additions  of  very  hot  water.  (Fig. 
175). 

The  Afferent  and  Efferent  Tube  Systems. — These,  as  will  appear 
from  a  glance  at  Figs.  176  and  179,  run  a  parallel  course  for  the  greater 
part  of  their  length — the  efferent  or  exhaust  tube  being  led  to  the  head 
of  the  table  in  order  that  it  may  be  controlled  by  the  anesthetist  sitting 
there.  The  afferent  tube  is  of  small  caliber,  since  it  conveys  only  gas, 
while  the  efferent  tube,  which  is  frequently  called  upon  to  conduct  water 
and  semi-fluid  feces,  must  have  greater  inside  diameter.  Both  tubes 
have  very  thick  walls  in  the  portion  which  passes  over  the  edge  of  the 
table  and  under  the  patient's  thigh.  This  is  to  obviate  the  danger  of  com- 
pression in  this  situation.  The  rectal  tube  is  a  short  single  tube  having 
a  bulb  about  3  inches  from  its  outer  end  supplied  with  5  to  7  fenestras. 
This  bulb  in  use  aids  in  the  prevention  of  leakage  in  case  of  a  lax 
sphincter,  while  the  multiple  fenestras  are  a  safeguard  against  closure  of 
the  tube  due  to  prolapsed  mucosa  or  to  fecal  particles  when  the  exhaust 
tube  is  opened.  Communication  between  the  rectal  tube  on  the  one 
hand,  and  the  afferent  and  efferent  tube  system  on  the  other,  is  estab- 
lished by  the  use  of  a  Y-shaped  tube  (Fig.  174)  of  glass  or  metal,  which 
stands  horizontally  between  the  patient's  thighs,  close  to  the  anus.  The 
upper  straight  arm  connects  with  the  afferent  tube  while  the  lower  curved 
branch  leads  to  the  efferent  connection.  By  reason  of  its  position  and 
construction,  this  Y-shaped  tube  acts  as  a  trap  to  catch  either  con- 
densed ether  from  the  afferent  tube  or  semi-fluid  matter  coming  from 
the  rectal  tube  when  the  exhaust  is  opened. 

A  strong  glass  tube  is  introduced  into  the  efferent  system,  as  shown 
at  ee,  Fig.  176.  This  serves  the  double  purpose  of  preventing  a  sag  in  the 
exhaust  tube  at  this  point  and  of  furnishing  a  rigid  support  for  the  slid- 
ing hooks  a,  which  form  the  principal  means  of  attaching  the  apparatus 
to  the  table.  The  ends  of  the  efferent  or  exhaust  tube  are  immersed  in 
a  few  inches  of  water  in  the  bottom  of  a  wide-mouthed  bottle,  which 
sits  on  the  floor  under  the  head  of  the  table,  or  in  the  drip  pan  con- 
nected with  the  latter.  This  bottle  serves  both  as  a  collector  of  any  fluid 
return  from  the  intestine  and  as  a  "tell-tale,"  since  the  amount  of  gaseous 
return  following  the  opening  of  the  exhaust  is  readily  appreciated  when 
it  is  seen  or  heard  bubbling  through  the  water.  Continuous  leakage 
from  the  exhaust  is  prevented  by  a  spring  clip  lih,  which  is  modified, 
as  shown  in  Fig.  177,  so  that  the  afferent  tube  is  held  in  relation  with  one 
of  the  finger  rests  of  the  clip.  This  relation  of  clip  and  afferent  tube  in- 
sures the  closure  of  the  latter  by  the  same  finger  pressure  which  opens 
the  former.  Gas  is  thus  prevented  from  entering  the  intestines  as  long 
as  the  exhaust  is  open.  For  the  sake  of  keeping  it  in  a  definite  position, 
this  combination  clip  is  attached  to  the  table  by  a  long  wire  hook.  Since, 
in  some  cases,  it  is  necessary  temporarily  to  supplement  the  colonic  ad- 


450 


ANESTHESIA 


ministration  by  the  addition  of  ether  by  mouth,  a  T-tube,  bb,  Fig.  176,  is 
placed  in  the  afferent  system  close  to  the  generator,  and  a  small  rubber 
tube  is  led  off  and  closed  by  a  spring  clip. 

In  mouth  and  throat  cases,  where  it  is  desirable  for  the  patient  to 
retain  an  active  coughing  reflex,  it  has  proved  of  advantage  to  introduce 
a  small  mica-plate  check  valve  beyond  the  origin  of  the  accessory  mouth 


Fig.  177. — Combination  Clip  with  Hook. 


^777777^/^'^/^^}///^//// 

[^ 

[-v.v.,v///^^W^^ 

'^^^^';^'i?y,r^ 

™"'*bss^?'^ 

tube.  Coughing  produces  a  very  marked  increase  in  intra-abdominal 
pressure,  and  in  some  cases  before  the  introduction  of  this  valve  a 
paroxysm  of  coughing  has  resulted  in  the  driving  of  fecal-stained  fluid 
back  into  the  generating  chamber.  With  the  check  valve,  as  shown  in 
Fig.  178,  this  cannot  occur.  When  violent  coughing  is  permitted,  it  is 
necessary  to  open  the  exhaust  during  each  paroxysm,  lest  the  rectal  tube 
be  extruded  by  the  effort ;  or  an  automatic  safety  valve  may  be  arranged 
by  leaving  off  the  spring  clip  and  immersing  the  distal  end  of  the  exhaust 
tube  in  about  18  inches  of  water.  (Fig.  179.)  This  height  of  water  will 
be  sufficient  to  prevent  escape  of  gas  at  20  mm.  pressure,  but  readily 

permits  escape  at  the 
higher  pressure  incident 
to  coughing.  When  this 
device  is  used  the  intes- 
tine may  be  emptied  of 
gas  by  simply  raising  the 
end  of  the  exhaust  tube 
to  the  surface  of  the 
water. 

Technique  of  Method. 
— Preparation  of  the 
Patient. — One  of  the 
most  important  consider- 
ations, as  observed  by  all 
workers  with  intestinal  anesthesia,  is  the  thorough  cleansing  of  the  colon. 
This  is  accomplished  by  a  cathartic  (castor  oil)  given  the  night  preceding 
the  operation  and  followed  in  the  morning  by  high  soapsuds  enemata  re- 
peated until  the  return  is  clear.  In  Sutton's  cases  three  enemata,  1%  to 
2  hours  apart,  were  regarded  as  the  minimum  number.  In  alcdholic  and 
very  muscular  subjects,  and  in  operations  on  the  mouth  or  upper  respira- 
tory tract,  it  has  been  found  useful  to  give  1/6  to  14  grain  of  morphin 


Fig.  178. — Check  Valve  Used  on  Afferent  Tube 
When  Coughing  is  to  be  Permitted.  (Partial 
sectional  view.)  thb,  thick  walled  brass  tube  con- 
necting with  generator;  tb,  thin-walled  brass  tube 
—notched  on  end  toward  valve — connecting  with 
main  afferent  tube;  gt,  glass  tube  surrounding 
valve  chamber;  mp,  mica-plate  valve;  re,  cuffs  of 
rubber  tubing  connecting  glass  and  brass  tubes. 


ANESTHESIA  BY  COLONIC  ABSORPTION  OF   ETHER      451 

and  1/120  to  1/100  grain  of  scopolamin  hypodermically  1  hour  before 
operation. 

The  Administration. — Before  the  patient  is  brought  to  the  etheriz- 
ing room,  the  anesthetist  affixes  the  apparatus  to  the  table,  as  shown  in 
Fig.  179,  except  that  the  rectal  tube  is  not  attached  and  the  Y-tube  and 
its  connections  are  allowed  to  hang  down  at  the  side  of  the  table,  while 
the  accessory  mouth  tube  is  permitted  to  hang  from  the  side  of  the  gen- 
erator.    The  ether  reservoir  is  charged,  the  water  jacket  is  filled  with 


Fig.  179. — Sketch  of  Pipe-Line  System  with  Safety  Valve  Water  Manometer  At- 
tached.    Note  that  combination  clip  is  not  used  with  this  arrangement. 


water  at  about  90°  F.,  and  the  electric  lamp  is  connected  with  a  plug  in 
the  wall,  hut  not  lighted  at  this  time.  The  end  of  the  exhaust  tube  is 
placed  in  the  "tell-tale"  bottle  under  the  table. 

•  The  anesthesia  is  then  started  by  the  pulmonary  method,  and  carried 
to  a  stage  of  partial  relaxation,  when  the  patient  is  brought  to  the  operat- 
ing room  and  placed  on  the  table.  The  rectal  tube,  well  greased,  is  then 
quickly  inserted  until  the  bulb  lies  just  inside  the  sphincter,  the  anes- 
thetist before  starting  the  initial  anesthetic  having  protected  his  left 
hand  with  a  rubber  glove.  The  patient's  left  thigh  is  then  raised,  and 
the  branch  tube  brought  under  it  to  its  proper  position  and  connected 
with  the  rectal  tube.  For  this  brief  period  the  cone  has  been  held  over 
the  patient's  face  by  a  nurse.  The  anesthetist  then  removes  his  rubber 
glove,  takes  his  place  at  the  patient's  head,  and  slowly  turns  on  the  oxy- 
gen. As  soon  as  this  is  done  the  cone  may  be  removed  from  the  patient's 
face.  If  the  operation  does  not  involve  the  patient's  mouth,  it  is  best 
to  cover  this,  and,  if  possible,  the  nose  as  well,  with  three  or  four  large 
sterile  towels  which,  by  causing  a  certain  amount  of  rebreathing,  im- 
pede the  elimination  of  ether  from  the  lungs.  If,  during  the  change 
from  the  pulmonary  to  the  colonic  method,  the  patient  has  "come  out" 
and  begun  to  make  troublesome  voluntary  movements,  he  can  be  quickly 
"put  under"  by  admitting  ether  vapor  to  the  space  under  the  towels 
through  the  accessory  mouth  tube. 


452  ANESTHESIA 

As  soon  as  pressure  in  the  colon  has  been  raised  to  the  required  20 
mm.,  the  exhaust  should  be  opened  and  the  gut  allowed  to  empty  itself. 
This  process  of  filling  and  emptying  the  intestine  should  be  repeated 
three  or  four  times  in  order  to  eliminate  as  thoroughly  as  possible  the 
natural  gases  of  the  bowel.  The  needle  valve  of  the  oxygen  tank  is  then 
set  at  a  point  which  just  maintains  the  required  20  mm.  pressure,  and 
usually  demands  little  or  no  further  adjustment  during  the  rest  of  the 
operation.  If  the  patient  tends  to  come  out  from  the  influence  of  the 
anesthetic,  the  bowel  may  be  emptied  from  time  to  time  to  carry  out 
any  intestinal  gases  which  tend  to  dilute  the  anesthetic  mixture.  If,  on 
the  other  hand,  the  anesthesia  continues  sujfficiently  deep,  no  further  use 
of  the  exhaust  need  be  made  until  the  end  of  the  operation.  This  is  be- 
cause the  oxygen  is  absorbed  by  the  bowel  with  the  same  ease  as  the 
ether  vapor,  in  fact,  more  rapidly,  so  that  no  residue  of  the  anesthetic 
remains. 

When  air  is  used  as  a  vehicle,  the  bowel  must  usually  be  emptied 
every  5  or  10  minutes,  as  in  this  case  a  nitrogen  residue  tends  to  accu- 
mulate and  to  act  as  a  diluent  of  the  freshly  added  anesthetic  mixture. 
Whenever  possible,  oxygen  should  be  used  instead  of  air  as  a  vehicle. 
The  reasons  for  this,  are:  (1)  It  reduces  the  dangers  of  anesthesia; 
(2)  it  greatly  diminishes  the  rapidity  and  depth  of  respiration,  in 
some  cases  even  causing  the  phenomenon  of  apnea  or  hyperoxygenation, 
thus  greatly  reducing  the  loss  of  ether  through  the  lungs;  and  (3)  it 
obviates  the  necessity  of  the  frequent  use  of  the  exhaust,  and  hence 
contributes  to  the  smoothness  of  the  anesthesia  and  the  comfort  of  the 
anesthetist. 

In  the  ordinary  ease,  a  smooth  anesthesia  continues  from  this  point 
with  little  further  active  intervention  on  the  part  of  the  anesthetist.  The 
thermometer  must  be  watched  to  see  that  the  temperature  of  the  water 
bath  does  not  become  too  high.  When  the  temperature  tends  to  rise 
above  90°  F.,  the  incandescent  lamp  may  be  partly  withdrawn  from  the 
Avater  bath,  or  it  may  be  turned  off  for  a  few  minutes,  being  lighted 
when  the  temperature  has  fallen  to  88  or  89°  F.  If,  with  a  lighted 
10  candle  power  lamp  inserted  the  full  length  of  the  Avater  jacket,  a  tem- 
perature of  90°  F.  cannot  be  maintained,  it  is  certain  that  there  is  a  leak 
in  the  apparatus  or  from  the  patient's  sphincter,  necessitating  an  exces- 
sive flow  of  the  mixture  of  oxygen  and  ether  vapor  to  maintain  the  re- 
quired pressure. 

Too  shallow  narcosis  is  met  by  adjusting  the  face  towels  so  as  to 
cause  increased  rebreathing  of  the  exhaled  ether  (this  does  not  cause 
cyanosis  on  account  of  the  constant  absorption  of  oxygen  from  the  bowel), 
and,  if  this  is  not  sufficient,  by  introducing  the  anesthetic  mixture  under 
the  towel  from  the  accessory  tube. 

Too  deep  narcosis  is  met  by  temporarily  shutting  off  the  stream  of 


ANESTHESIA  BY  COLONIC  ABSORPTION  OF   ETHER      453 

oxygen  and  allowing  the  exhaust  to  remain  open  for  a  short  time,  or  by 
markedly  reducing  the  pressure  without  opening  the  exhaust. 

The  depth  of  narcosis  is  determined  by  the  pupils,  which  are  usually 
at  maximum  contraction  in  complete  anesthesia  by  this  method  (unless 
morphin  and  scopolamin  have  been  administered,  when  they  have  little 
value) ;  by  the  degree  of  muscular  relaxation,  and  by  the  color  which 
may  be  noted  from  the  lips  and  face,  but  better  from  the  color  of  the 
blood  in  the  wound.  The  character  of  the  respiration  is  of  less  value,  as 
the  patient  may  have  excellent  color,  though  breathing  very  infrequently. 
Short,  shallow,  jerky  respiration,  especially  when  associated  with  a  dusky 
color,  is  a  danger  sign,  just  as  it  is  in  the  pulmonary  method. 

The  writer  rarely  takes  the  pulse  except  in  cases  which  are  mani- 
festly doing  badly  or  where  cardiac  complications  are  known  or  sus- 
pected. Muscular  tone  is  best  determined  from  the  tension  of  the  jaw 
muscles  and  from  the  presence  of  voluntary  movement  of  the  tongue. 
It  is  the  writer's  habit  to  keep  one  finger  in  the  patient's  mouth  in  order 
to  detect  the  first  active  tightening  of  the  jaw  or  voluntary  movement  of 
the  tongue.  Sufficient  ether  need  not  be  given  to  make  the  lower  jaw 
entirely  relax,  but  merely  enough  to  prevent  actual  biting  of  the  finger. 
Difficulty  in  breathing  is  readily  overcome  by  extending  the  head  on 
the  neck  by  simply  pulling  with  the  finger  upon  the  upper  incisors.  This 
has  always  been  sufficient,  so  that  in  the  entire  series  of  cases  here  re- 
ported neither  mouth  gag  nor  tongue  forceps  have  been  used  to  improve 
the  respiration  of  the  patient. 

At  the  end  of  the  operation  the  bowel  is  filled  with  oxygen  to  a  pres- 
sure of  20  mm.  and  emptied  several  times,  these  "oxygen  enemata"  serv- 
ing to  carry  off  the  greater  part  of  the  unabsorbed  ether.  Occasionally 
it  seems  advisable  to  massage  the  abdomen  in  the  direction  of  the  colon 
before  removing  the  rectal  tube^  but  this  is  not  usually  necessary.  The 
rectal  tube  is  then  withdrawn  and  disconnected  from  the  Y-tube. 

After-treatment. — As  soon  as  the  patient  is  returned  to  bed  a  high 
soapsuds  enema  is  given,  being  siphoned  off  after  a  few  minutes  if  neces- 
sary. This  treatment  is  repeated  a  half  hour  later.  Vomiting  is  usually 
absent;  when  present  it  is  very  rarely  severe,  the  patients,  curiously 
enough,  disclaiming  any  feeling  of  nausea.    Eecovery  is  rapid. 

The  possibility  of  the  transmission  of  typhoid,  amebic  colitis,  or 
other  intestinal  infection  from  one  patient  to  another  is  prevented  by 
keeping  the  rectal  tube  and  the  Y-tube  in  a  1  per  cent  solution  of  forma- 
lin between  operations.  The  glass  tip  of  the  accessory  mouth  tube,  when 
not  in  use,  is  kept  in  the  same  solution. 

Discussion  of  Cases. — Up  to  the  present  time  the  writer  has  adminis- 
tered ether  by  this  method  to  about  140  cases  on  the  surgical  service  of 
Eoosevelt  Hospital.  Of  this  number  careful  records  were  taken  of  the 
first  100  cases.     Of  the  remaining  40,  mostly  private  eases,  no  detailed 


454  ANESTHESIA 

records  have  been  made.  It  may  be  said,  however,  that  all  were  satis- 
factory and  that  untoward  results  occurred  in  none.  In  only  one  case — 
the  second  of  the  series — was  an  attempt  made  to  administer  the  anes- 
thetic per  rectum  from  the  beginiiing.  This  proved  so  slow,  and  was  so 
uncomfortable  and  distasteful  to  the  patient,  that  after  about  20  minutes 
a  cone  was  used  to  complete  the  initial  establishment  of  the  anesthesia. 
Inasmuch  as  there  is  no  real  indication  for  beginning  the  administra- 
tion by  rectum,  the  writer  has  never  made  a  second  attempt  to  do  so. 

Of  the  100  cases  in  the  recorded  series,  91  were  ward  patients  and  9, 
private  patients.  The  age  range  was  2  to  77  years.  The  operations  were 
as  follows: 

Tumors,  glands,  etc.,  of  neck 31 

Amputations  of  breast 9 

Goiters  and  thyroglossal  cysts 8 

Craniotomies 6 

Corrections  of  old  fractures  of  limb 5 

Resections,  sutures  and  osteotomies  of  inferior  maxilla •      5 

Partial  excision  of  the  tongue 4 

Staphylorrhaphy 4 

Tracheotomy 3 

Mastoid 3 

Inguinal  hernia ■  ■  ■     2 

Removal  of  parotid  tumors 2 

Resection  and  osteotomies  of  superior  maxiUa 2 

Removal  of  Gasserian  ganglion 2 

Skin  grafting 2 

Orchidopexy 

Hydrocele 

Appendectomy 

Nephrotomy 

Ludwig's  angina 

Enucleation  of  eye 

Resection  of  knee ,  • . 

Cervical  laminectomy 

Axillary  adenitis , 

Excision  of  sternomastoid 

Plastic  for  strictures  of   esophagus 

Laryngectomy 

Neuorrhaphy 

The  longest  operation  of  the  series  consumed  2  hours  and  20  min- 
utes; the  shortest,  5  minutes:  the  average  time  being  53  minutes. 

The  average  consumption  of  ether  was  87  grams  per  hour  in  the  64 
consecutive  cases  in  which  record  of  this  point  was  kept. 

Twelve  of  the  100  patients  had  preliminary  injection  of  morphin  and 
scopolamin. 


ANESTHESIA  BY  COLONIC  ABSORPTION   OF   ETHER      455 

In  25  cases,  oxygen  was  used  as  a  vehicle  for  the  ether  vapor. 

Forty-three  patients  had  at  some  time  during  the  operation  a  supple- 
mentary administration  hy  mouth  of  ether  or  chloroform. 

In  12  cases,  there  was  eructation  of  gas,  prohahly  indicating  the  pas- 
sage of  the  gas  into  the  stomach  from  the  distended  small  intestine.  Of 
these  only  4  occurred  in  the  71  cases  following  the  adoption  of  a  20  mm. 
maximum  pressure  in  the  bowel. 

In  only  18  cases  was  there  any  perspiration,  and  in  none  of  these 
was  it  profuse. 

Forty-three  patients  vomited  or  regurgitated  stomach  contents  after 
operation;  of  these,  several  disclaimed  any  sensation  of  nausea. 

Twelve  had  abdominal  pain. 

Five  had  bloody  stools  or  blood-streaked  return  from  the  post-anes- 
thetic enemata.  All  cleared  up  in  from  a  few  hours  to  3  days,  and  in 
none  was  the  loss  of  blood  accompanied  by  noticeable  weakness  or  ab- 
dominal pain.  The  most  severe  of  the  cases  continued  to  pass  small 
quantities  of  blood  for  3  days,  during  which  the  patient  also  vomited 
persistently.  This  patient.  Case  XXVI  of  the  series,  was  the  last  save 
one  in  which  any  hemorrhage  (beyond  the  negligible  amount  occasionally 
caused  mechanically  by  the  rectal  tube)  has  occurred. 

Case  XCVII,  as  an  incident  to  the  Introduction  of  a  new  form  of 
ether  evaporator,  was  treated  to  an  excessively  concentrated  vapor,  so 
that  great  care  was  necessary  to  prevent  narcosis  from  becoming  too  deep. 
In  the  first  3  days  following  the  operation  this  patient  had  5  bloody 
stools.  He  felt  no  discomfort,  however,  and  was  discharged  on  the  fifth 
day  in  perfect  general  condition. 

In  the  series  of  cases  to  date  there  have  been  5  deaths  from  all  causes. 
In  none  of  these,  in  the  judgment  of  the  operating  surgeon,  was  the 
method  of  administering  the  anesthetic  a  contributing  factor.  A  brief 
statement  of  the  conditions  in  each  of  these  cases  follows : 

Case  I. — Large,  heavy  man,  moderately  alcoholic.  Operation,  partial 
excision  of  the  tongue  for  epithelioma.  Patient  somewhat  blue;  pulse 
small  and  rapid  throughout  operation.  Died,  apparently  of  operative 
shock,  about  two  hours  after  return  to  ward. 

Case  II. — Large,  heavy  man.  Age  35.  Moderately  alcoholic.  Oper- 
ation, tracheotomy  and  removal  of  cervical  glands  as  a  preliminary  to 
laryngectomy  for  carcinoma  of  larynx.  Anesthesia  was  "shalloV 
throughout,  patient  coughing  and  groaning  frequently.  Made  prompt 
ether  recovery,  but  died  2  days  after  of  pneumonia. 

Case  XXV. — ^^Fairly  well-nourished  man;  age  53;  moderately  alco- 
holic. Operation,  hemi-excision  of  the  tongue  and  removal  of  right  cer- 
vical glands  for  epithelioma.  Patient  took  initial  anesthetic  slowly,  and 
was  markedly  cyanotic.  Color  and  general  condition  improved  after  be- 
ginning  of  the   administration   per   rectum.      Anesthesia   was   shallow 


456  ANESTHESIA 

throughout,  patient  swallowing  frequently.  Late  in  the  operation  there 
was  a  markpd  hemorrhage,  and  shortly  afterward — 1  hour  and  35  min- 
utes after  the  beginning  of  the  operation — ^the  patient  died. 

Case  XLIY. — Muscular  man,  age  24;  brought  to  hospital  almost 
moribund  with  compound  depressed  fracture  of  skull.  After  operation 
lasting  35  minutes,  the  patient  left  the  table  improved,  but  never  re- 
gained consciousness  and  died  2  days  later. 

Autopsy  showed  extensive  fractures  of  vault  and  base,  extensive  lacer- 
ation of  brain,  and  marked  subdural  and  epidural  hemorrhage.  The 
colon  was  normal,  showing  no  injurious  effects  from  the  ether. 

Case  XLYII. — Slender  negro,  age  31;  brought  to  hospital  in  ambu- 
lance with  extreme  dyspnea  of  sudden  onset.  Operation,  low  trache- 
otomy, with  patient  in  sitting  posture  on  account  of  orthopnea.  On  ac- 
count of  this  position  the  rectum  was  compressed  by  the  weight  of  the 
upper  bowel,  and  introduction  of  ether  vapor  and  oxygen  into  the  colon 
was  almost  impossible.  The  operation  gave  little  relief,  but  ether  recov- 
ery was  satisfactory.  Dyspnea  and  cardiac  weakness  progressively  in- 
creased, and  two  days  later  the  patient  died. 

Autopsy  showed  a  large  false  aneurysm  of  the  descending  arch  of  the 
aorta.    Colon  normal. 

One  other  death  has  occurred  in  Eoosevelt  Hospital  from  the  adminis- 
tration of  ether  by  this  method.  Another  member  of  the  interne  staff 
administered  the  anesthetic  in  this  instance,  but  the  case  came  under  the 
writer's  observation  both  during  and  after  the  operation. 

The  patient  was  a  well-nourished  child,  five  years  of  age,  who  had 
been  anesthetized  on  two  previous  occasions  for  the  correction  of  harelip 
and  the  removal  of  adenoids.  The  operation  in  question  was  a  staphy- 
lorrhaphy lasting  about  50  minutes.  Throughout  the  operation  there  was 
noticeable  difficulty  in  maintaining  a  smooth  narcosis,  the  latter  being 
too  deep  and  too  shallow  by  turns.  In  the  course  of  the  shallow  inter- 
vals a  little  chloroform  was  given  several  times  on  a  "sponge  stick." 
There  was  no  excessive  loss  of  blood.  Toward  the  close  of  the  operation 
the  patient's  color  became  very  bad,  and  the  pulse  small  and  rapid.  She 
was  hurried  to  the  ward,  stimulated,  and  given  external  heat.  In  the 
course  of  a  half  hour  she  became  restless  and  talkative,  calling  for  water 
and  asking  to  be  taken  home,  but  apparently  recognizing  no  one  about 
her.  She  did  not  vomit.  The  pulse  continued  rapid  and  small,  and  an 
intravenous  infusion  was  given  with  slight  temporary  benefit.  After  this 
she  gradually  relapsed  again  into  unconsciousness,  and  about  two  hours 
after  operation  she  died.    Unfortunately  an  autopsy  was  not  permitted. 

It  is  the  writer's  belief  that  this  method,  safeguarded  by  such  im- 
proved apparatus  as  that  described,  and  by  the  use  of  oxygen  as  a  vehicle 
for  the  ether  vapor,  is  one  of  extreme  safety  in  the  absence  of  definite 
intestinal  lesions. 


ANESTHESIA  BY   COLONIC  ABSORPTION   OF   ETHER      457 

Conclusions. — The  colonic  method  of  administration  of  ether  is  more 
complex  than  the  pulmonary  method  in  general,  and  requires  from  the 
anesthetist  a  broader  appreciation  of  the  physiological  factors  involved. 
For  these  reasons  alone  its  field  of  usefulness  is  limited  to  cases  in  which 
it  presents  distinct  advantage  over  the  pulmonary  method.  It  is,  there- 
fore, not  a  method  adapted  to  the  experimental  use  of  the  tyro,  hut 
rather  a  valuable  addition  to  the  armamentarium  of  the  trained  anes- 
thetist. We  may  summarize  the  indications  and  contra-indications  as 
follows : 

Indications. —  (1)  Operations  upon  the  respiratory  tract  (head, 
neck,  and  chest),  especially  such  as  lay  open  the  mouth,  larynx,  pharynx, 
and  trachea.  (2)  Operations  upon  patients  in  whom  absorption  must  be 
minimized  on  account  of  lung,  heart,  or  kidney  lesions.  (3)  Operations 
upon  patients  already  suffering  from  respiratory  embarrassment. 

CoNTKA-iNDiCATiONS. —  (1)  Operations  upon  patients  presenting 
lesions  of  the  alimentary  tract,  especially  such  as  might  cause  weakness 
of  the  wall  of  the  colon.  (2)  Laparotomies  in  general,  except  such  as  do 
not  open  the  general  peritoneal  cavity,  e.  g.,  suprapubic  cystotomy.  This 
is  because  of  the  interference  of  the  inflated  colon  with  the  work  of  the 
surgeon.  (3)  Operations  upon  patients  with  markedly  incompetent 
sphincter  ani  or  with  large  fistula  in  ano.  A  patient  with  an  open  appen- 
dicostomy  would  offer  the  same  difficulty  of  leakage.  (4)  Operations 
upon  patients  suffering  with  orthopnea.  In  these  cases  it  may  be  impos- 
sible to  inflate  the  colon  because  of  the  obstruction  caused  by  the  weight 
of  the  other  viscera  resting  upon  it.  (5)  Emergency  cases  in  general, 
because  of  the  lack  of  preparation  of  the  colon. 

Advantages. — The  points  in  favor  of  the  method  in  cases  in  which 
its  use  is  indicated  may  be  summed  up  as  follows :  (1)  Freedom  of  ope- 
rative field  from  contamination  by  the  anesthetist.  (2)  Ability  to  main- 
tain a  smooth  and  continuous  anesthesia  in  operations  involving  the 
respiratory  tract,  thus  shortening  the  time  and  reducing  the  shock  of 
operation.  (3)  Uniform  depth  of  anesthesia,  causing  light  narcosis  and 
marked  saving  in  ether.  This  saving  is  much  greater  when  oxygen  is 
used  as  the  vehicle.  (4)  Lessening  of  pharyngeal  and  bronchial  secre- 
tion, and  of  tonic  contraction  or  troublesome  relaxation  of  jaw  muscles. 

(5)  Ability  to  administer  oxygen  without  interruption  of  anesthesia. 

(6)  Minimized  loss  of  heat  during  operation  because  of  diminished  sweat- 
ing and  ether  refrigeration.  (7)  Eeduction  of  post-operative  vomiting 
and  nausea. 

Disadvantage. — The  only  point  against  the  method  in  cases  where 
its  employment  is  indicated  is  the  occasional  difficulty  in  maintaining 
profound  anesthesia  without  the  use  of  the  supplementary  mouth  tube. 


PAET    II 

OIL-ETHER  COLONIC  ANESTHESIA 

History. 

Animal  Experiments. 

Eemarks  on  the  Method. 

Preparation  of  the  Patient:    Preliminary  Medication. 

Administration. 

Control  of  the  Anesthesia. 

Physiology. 

Illustrative  Cases. 

History. — The  original  work  of  Cunningham  and  Sutton's  careful 
record  of  cases  were  prominent  factors  in  the  development  of  oil-ether 
colonic  anesthesia.  (See  Part  I  of  this  Chapter  for  a  history  of  rectal 
anesthesia.) 

In  1913  at  the  Seventeenth  International  Medical  Congress  in  Lon- 
don, the  senior  author  read  a  paper  on  Oil-ether  Anesthesia.  The  ex- 
perimental animal  work  was  completed  just  previous  to  this  date.  The 
practical  clinical  work  with  oil-ether  was  begun  at  the  People's 
Hospital,  and  the  first  successful  administration  was  in  September  of 
1913  to  a  patient  of  Dr.  I.  M.  Rothenberg,  his  brother  operating.  The 
work  was  completed  at  Columbus  Hospital  and  was  successfully  demon- 
strated at  other  hospitals  in  ISTew  York  City,  then  in  neighboring  cities. 

Animal  Experiments. — All  of  the  experimental  laboratory  work  was 
conducted  under  the  immediate  supervision  of  Professor  Wallace,  of  the 
pharmacological  department  of  the  University  and  Bellevue  Hospital 
Medical  College.  In  studying  the  anesthetic  value  of  ether  introduced  in 
solution  into  the  rectum,  about  twenty-four  experiments  on  dogs  were 
performed.  The  method  generally  employed  was  as  follows:  Several 
hours  before  the  administration  of  the  ether  a  saline  cathartic  was  given 
by  a  stomach  tube;  half  an  hour  before,  a  subcutaneous  injection  of 
morphin  sulphate  (from  0.001  to  0.03  gm.),  and  immediately  before,  a 
cleansing  enema  of  soap  and  water.  The  animal  was  then  placed  on  its 
back  on  a  holder,  and  a  fairly  stiff  rubber  catheter  was  inserted  into  the 
rectum  and  pushed  up  the  colon  for  a  distance  of  about  ten  inches.  The 
ether  solution  was  placed  in  a  bottle  with  an  outflow  tube  at  the  bottom 
attached  with  rubber  tubing  to  the  catheter.  The  bottle  was  then  raised 
to  any  desired  height,  from  one  to  six  feet,  and  the  flow  regulated  by  a 
screw  clamp  on  this  tubing. 

458 


ANESTHESIA  BY   COLONIC  ABSORPTION   OF   ETHER      459 

In  the  first  experiment  performed,  a  five  per  cent  ether  solution  in 
normal  saline  was  used.  About  500  c.  c.  of  this  solution  was  slowly  in- 
jected into  the  colon.  A  very  mild  excitement  stage  ensued,  and  com- 
plete anesthesia  continued  for  thirty  minutes,  gradual  recovery  then 
taking  place.  There  was  a  watery  discharge  from  the  rectum  during  the 
recovery  stage,  but  no  diarrhea  on  the  following  day.  This  experiment 
was  repeated  on  a  second  dog  under  the  same  conditions,  but  complete 
anesthesia  was  not  obtained.  I  next  suggested  oil-ether,  with  the  idea  of 
reducing  the  bulk.  Ether  is  miscible  in  all  proportions  in  oil.  The  oil 
also  prevents  irritation,  and  its  great  affinity  for  ether  prevents  a  too 
rapid  absorption  of  the  latter;  furthermore,  when  the  oil-ether  mixture 
is  in  the  colon,  as  the  ether  leaves  the  oil  in  gaseous  form,  heat  is  ex- 
tracted from  surrounding  parts,  including  the  oil-ether  mixture  and  the 
colon.  This  cooling  checks  both  evaporation  and  absorption,  and  regu- 
lates the  doses  at  all  times.  The  difference  between  the  slow  absorption 
from  the  colon  and  the  rapid  elimination  from  the  lungs  is  the  third 
factor  that  assists  in  automatically  regulating  the  anesthesia. 

Experiments  under  the  supervision  of  the  junior  author  were  then 
made  to  discover  if  there  was  any  difference  in  time  in  the  ether  separat- 
ing from  the  oils.  The  oils  used  were  olive,  cotton-seed,  cod  liver,  neats- 
foot,  paraffin  oils,  and  Russian  mineral  oil;  also  milk  and  cream.  The 
same  quantity  of  ether  and  of  the  oils  was  placed  in  separate  test  tubes 
and  put  in  a  water  bath  kept  at  a  temperature  of  approximately  body 
heat.  No  difference  in  time  was  found  in  the  separation  of  the  ether 
from  the  different  oils. 

The  experimental  procedure  with  animals  was  then  changed  in  that 
the  ether  was  given  dissolved  in  oils  and  in  greater  concentration ;  in  one 
experiment  in  which  100  c.  c.  of  ether  in  250  c.  c.  of  olive  oil  (i.  e.,  forty 
per  cent)  was  inserted  into  a  dog  of  10  kg.,  the  animal  became  com- 
pletely narcotized  in  one  hour,  when  the  whole  solution  had  been  in- 
serted. The  anesthesia  persisted,  with  a  good  pulse  and  regular,  deep 
breathing  for  forty-five  minutes,  when  the  breathing  became  short  and 
irregular.  The  respiration  gradually  became  weaker  and  stopped  fifteen 
minutes  later.  No  effort  was  made  to  save  the  animal.  This  dog  had 
received  a  large  amount  of  morphin  preliminary  to  the  ether.  In  two 
other  experiments  in  which  no  morphin  was  given,  one  dog  (weight  6 
kg.)  received  150  c.  c.  of  a  40  per  cent  ether  solution,  and  one  (weight 
6  kg.)  190  c.  c.  of  40  per  cent  solution.  In  neither  was  complete  anes- 
thesia obtained.  In  the  remaining  experiments  the  ether  was  given  in 
solution  in  oil  from  55  to  75  per  cent  the  amount  of  ether  injected  being 
from  50  to  75  c.  c.  Ten  successful  experiments  were  carried  out,  with 
complete  anesthesia  and  no  alarming  symptoms. 

The  shortest  time  required  for  surgical  anesthesia  was  five  minutes, 
the  longest  fifty.     The  duration  of  anesthesia  after  the  ether  insertion 


460  ANESTHESIA 

was  stopped  averaged  about  an  hour,  except  in  cases  in  which  the  colon 
was  washed  out,  when  recovery  set  in  more  promptly.  In  no  case  has 
there  been  any  evidence  of  more  than  a  mild  irritation  of  the  gut  follow- 
ing the.  ether  introduction,  and  this,  when  present,  has  disappeared 
within  twenty-four  hours.  A  flushing  of  the  colon  with  a  large  amount 
of  fluid  has  shortened  the  duration  of  anesthesia,  and  the  subsequent 
injection  of  oil  prevented  or  lessened  rectal  irritation.  The  following  is 
the  record  of  an  experiment : 

Dog,  weight  12  kg.,  given  10  gm.  magnesium  sulphate  in  100  c.  c. 
water  by  stomach  at  10 :30  A.  M.  Morphin  sulphate,  0.02  gm.  at  3  :20 
P.  M.  Eectum  washed  out  at  3  :30  P.  M.  At  3  :45,.125  c.  c.  ether  solu- 
tion (75  per  cent  in  cottonseed  oil)  injected  into  colon  at  a  pressure  of 
20  mm.  Hg.  At  4:01,  complete  anesthesia,  with  no  preliminary  excite- 
ment stage.  At  4 :05,  rectum  washed  with  water.  At  4 :10,  recovery  be- 
ginning. At  5,  animal  able  to  run  about.  Slight  diarrhea  during  night 
and  following  day. 

Remarks  on  the  Method. — One  of  the  underlying  thoughts  in  evolv- 
ing oil-ether  anesthesia  is  to  avoid  certain  dangers  that  pertain  to  in- 
travenous anesthesia.  The  only  apparatus  needed  are  a  small  catheter, 
a  funnel  to  hold  the  mixture,  and  a  measuring  cylinder.  On  account  of 
the  gradual  and  equal  absorption  of  the  ether  from  the  colon,  and  of  its 
rapid  evaporation  from  the  lungs,  it  is  a  comparatively  safe  anesthesia, 
provided  the  same  care  and  attention  are  given  to  details  as  with  any 
inhalation  anesthetic.  Mucus  and  saliva  are  absent,  and  the  patient's 
lungs  and  stomach  are  spared.  As  yet  only  ether  has  been  experimented 
with.  The  preparation  of  the  patient  should  be  the  same  as  that  for  ether- 
vapor  anesthesia  by  rectum.     This  is  most  important  and  is  as  follows : 

Preparation  of  the  Patient. — A  cathartic  of  castor  oil  should  be 
given  the  night  preceding  the  operation,  followed  in  the  morning  by 
warm  water  enemas  one  hour  apart  until  the  return  is  clear.  The  pa- 
tient should  then  be  allowed  to  rest  for  two  to  three  hours. 

Preliminary  Medication. — One  hour  before  the  introduction  of 
the  mixture,  5  to  20  grains  of  chloretone  in  a  suppository  or  dissolved  in 
4  drams  of  ether  and  mixed  with  an  equal  amount  of  olive  oil  are  given 
per  rectum  with  the  patient  in  the  Sims  position.  Both  the  preliminary 
and  the  mixture  should  be  administered  very  slowly  through  a  funnel 
which  is  attached  to  the  end  of  the  catheter  which  has  been  well  lubri- 
cated and  inserted  4  inches  into  the  rectum. 

As  paraldehyd  mixes  with  oil  and  ether  in  all  proportions,  it  may  be 
found  that  two  to  four  drams  of  paraldehyd  with  an  equal  amount  of 
olive  oil  and  given'  alone  is  preferable  as  a  preliminary.  As  isopral,  like 
chloretone,  has  a  slight  local  analgesic  as  well  as  general  hypnotic  effect, 
this  drug  may  possibly  prove  to  be  superior  as  a  preliminary  to  the  others 
mentioned.    Thirty  minutes  after  the  chloretone  or  paraldehyd  has  been 


ANESTHESIA  BY  COLONIC  ABSORPTION   OF   ETHER      461 

given,  one-twelfth  to  one-quarter  of  a  grain  of  morphin  with  1/200  to 
1/100  grain  of  atropin  is  given  hypodermatically.  For  alcoholics  and 
athletes  the  following  is  suggested:  Two  hours  before  operation  give 
1/100  grain  of  hyoscin  hydrobromid  hypodermatically  and  one  hour  be- 

Ty       ^3?       ^Z7       <C7 ^C7 

O   O   O   O   O   O    "^'"""' 

J^ iCi O O ^2i 

Fig.   180. — Gwathmey  Rectal  Irrigation  Tube. 

fore  the  operation  repeat  the  hyoscin  with  one-quarter  grain  of  morphin. 

Administration. — Twenty  minutes  after  the  hypodermic  injection,  the 
oil-ether  mixture  should  be  given  slowly,  allowing  one  minute  for  each 
ounce,  with  the  patient  in  the  Sims  position  in  his  own  bed.  If  the 
patient  is  in  a  ward  the  bed  should  be  screened. 

It  may  be  administered  without  exposure  of  the  patient,  the  rectal  tube 
being  introduced  between  two  suitably  adjusted  sheets.    The  patient  lies 


Fig.   181a. — Showing   Patient  in  Position  for  Oil-ether  Administration. 

on  the  left  side  in  perfect  comfort,  in  marked  contrast  to  the  disagree- 
able supine  position  required  for  inhalation  anesthesia.  The  preliminary 
medication,  the  percentage,  and  amount  of  the  mixture  (roughly,  one 
ounce  to  every  twenty  pounds  of  body  weight)  vary  with  the  age,  size  and 
general  condition  of  the  patient.  A  50  to  65  per  cent  solution  is  sufficient 
for  children  and  weak,  anemic  adults,  while  a  75  per  cent  solution  is 


462  ANESTHESIA 

usual  with  normal  adults,  but  this  should  never  be  exceeded.  The  pa- 
tient should  be  kept  perfectly  quiet,  not  being  permitted  to  talk,  and  ten 
to  twenty  minutes  should  be  allowed  for  the  anesthetic  to  take  effect 
before  the  patient  is  moved.  Eight  ounces  of  the  75  per  cent  mixture 
will  cause  the"  anesthesia  to  last  from  two  and  a  half  to  three  hours.  N^o 
more  than  eight  ounces  should  ever  be  given,  regardless  of  the  patient's 
weiglit. 

Control  of  the  Anesthesia. — The  anesthetist  has  good  control  of  the 
ether  at  all  times.  If  the  patient  approaches  the  danger  zone,  as  indi- 
cated by  loss  of  lid  reflex,  slight  cyanosis  or  stertor,  withdrawal  of  the 
mixture  remaining  in  the  colon  will  usually  immediately  remedy  the 
trouble.  If  this  is  insufficient,  a  Connell  breathing-tube  will  usually 
lighten  the  anesthesia.  If,  however,  this  does  not  suffice,  the  patient  may 
be  restored  to  safety  by  opening  a  vein  and  introducing  1,000  to  2,000 
c.  c.  of  normal  saline  solution.  If  respiratory  arrest  occurs,  a  bag  filled 
one-third  full  of  carbon  dioxid  gas  is  placed  over  the  face,  and  with  arti- 
ficial respiration  this  condition  is  remedied.  If  the  patient  is  too  lightly 
narcotized,  a  towel  placed  over  the  face  and  slightly  puckered  just  above 
the  nose  and  mouth,  but  held  securely  to  the  face  around  the  edges,  will 
prevent  the  escape  of  the  ether  vapor  and  induce  a  certain  amount  of 
rebreathing,  thus  preventing  the  dilution  of  the  anesthetic  with  the  out- 
side air.  In  this  way  the  anesthesia  is  deepened.  If  this  is  insufficient,  a 
few  drops  of  chloroform  or  ether  upon  the  towel  will  satisfactorily  com- 
plete the  narcosis. 

Note  :  No  preliminary  medication  is  needed  for  children  under  nine 
years  of  age. 

Physiology. — When  the  oil-ether  mixture  is  introduced  into  the  rec- 
tum, it  requires  a  very  short  time  to  heat  the  mixture  from  room  to  body 
temperature.  When  this  occurs  some  of  the  ether  leaves  the  oil  in  the 
form  of  a  gas.  It  is  then  absorbed  by  the  blood  circulating  in  the  small 
capillaries  surrounding  the  colon.  From  this  on  the  physiology  is  the 
same  as  with  ether  Avhen  introduced  by  the  vapor  method. 

The  odor  of  ether  is  perceptible  on  the  patient's  breath  within  three 
to  four  minutes.  The  breathing  is  normal.  If  stertor  commences  it  in- 
dicates unnecessary  deepening  of  the  anesthesia.  If  cyanosis  is  present, 
it  is  evidence  of  an  overdose  or  an  imperfect  airway.  While  the  lid  re- 
flex is  quite  active,  a  very  great  degree  of  relaxation  exists  throughout 
the  whole  muscular  system.  When  preliminary  medication  is  given  as 
directed,  the  pulse  remains  nearer  normal  during  anesthesia. 

Four  factors  tend  to  automatically  maintain  the  depth  of  anesthesia : 

(1)  The  rate  of  evaporation  of  the  ether  from  the  oil,  which  is  always 
constant  in  normal  individuals.  (2)  The  distention  of  the  colon.  Sut- 
ton discovered  that  when  the  colon  was  fully  distended  not  so  much  ether 
was  absorbed  as  when  it  was  only  partially  distended.     (3)  As  the  ether 


ANESTHESIA  BY  COLONIC  ABSORPTION   OF   KTlTl^li      4G3 

leaves  the  oil,  both  the  mixture  and  the  gut  all  cooled  oil'  by  the  process. 
This  retards  both  elimination  and  absorption.  This  process,  however, 
does  not  noticeably  affect  the  temperature  of  the  patient,  which  remains 
constant.  (4)  The  fourth  factor  is  the  difference  between  the  absorptive 
power  of  the  colon  and  the  eliminative  capacity  of  the  lungs. 

That  these  four  factors,  acting  harmoniously,  produce  as  even  a  plane 
of  anesthesia  as  can  possibly  be  maintained  by  any  other  method,  is  dem- 
onstrated by  the  sphygmographic  tracing  of  a  dog  under  the  oil-ether 
anesthesia  for  one  hour.  The  pulse  and  respiratory  tracing  did  not  vary 
during  the  entire  time. 

In  many  hundreds  of  cases  surgically  anesthetized  hy  this  method  in 
which  no  supplementary  anesthetic  was  used,  the  pulse,  respiration,  re- 
flexes, and  blood  pressure  all  remained  constant. 

When  the  operation  is  completed,  the  rectal  tubes  already  mentioned 
should  be  placed  in  position,  as  high  up  the  colon  as  convenient  with- 
out traumatism,  and  cold  water  soapsuds  introduced  through  one  tube 
and  drawn  off  through  the  other;  two  to  four  ounces  of  olive  oil  should 
then  be  introduced  into  the  rectum  and  the  tubes  withdrawn.  The  pa- 
tient should  be  gently  returned  to  bed,  with  as  little  jolting  or  handling 
as  possible;  the  room  should  be  darkened,  and  free  ventilation  secured. 

In  some  of  the  cases  mentioned  novocain  was  injected  locally  at  the 
site  of  the  operation  after  the  patient  came  on  the  operating  table.  In 
other  cases  no  local  anesthetic  was  used.  Wliere  a  local  anesthetic  is 
used  at  the  site  of  the  operation,  and  the  ether  is  administered  by  the  oil- 
ether  rectal  method,  every  principle  of  anoci-assoeiation,  as  enunciated 
by  Crile,  will  be  fulfilled.  The  patient  awakes  quietly,  without  nausea, 
vomiting,  or  pain,  the  analgesia  continuing  for  some  time  after  con- 
sciousness is  restored. 

Illustrative  Cases. — Before  the  dosage  was  accurately  determined, 
the  following  case  was  given  over  twice  the  amount  of  chloretone  neces- 
sary as  a  preliminary,  and  three  ounces  too  much  of  the  oil-ether  mix- 
ture ;  the  correct  dosage  for  a  patient  weighing  100  pounds  being  chlore- 
tone grs.  5,  and  oil-ether  mixture  (75  per  cent)  five  ounces. 

Case  I. — A  woman  weighing  less  than  one  hundred  pounds,  about 
thirty  years  of  age,  was  operated  upon  for  pelvic  cellulitis.  She  was 
given  one-quarter  grain  of  morphin  and  one  one-hundred  and  fiftieth 
grain  of  atropin  hypodermatically,  and  a  suppository  containing  20 
grains  of  chloretone,  as  preliminary  medication.  Eight  ounces  of  a  75 
per  cent  solution  of  ether  in  oil  was  given  as  the  anesthetic.  This  pa- 
tient evidently  received  an  overdose  of  preliminary  medication,  also 
of  the  anesthetic.  Eespiratory  arrest  occurred  a  few  minutes  after  she 
was  placed  upon  the  operating  table.  Artificial  respiration,  stretching 
of  the  sphincter,  and  the  intravenous  introduction  of  1,000  c.  c.  of  nor- 
mal saline  were  employed.     A  bag  containing  a  small  amount  of  car- 


464  ANESTHESIA 

bon  dioxid  was  then  placed  over  her  face,  whereupon  respiration  recom- 
menced immediately.  During  the  time  of  respiratory  arrest,  which  lasted 
eight  minutes,  the  pulse  was  full,  regular,  and  approximately  normal. 
The  color  of  the  lips  and  tongue  was  good.  The  operation  was  satisfac- 
torily performed,  and  the  patient  was  returned  to  bed.  An  uneventful 
recovery  is  recorded,  with  no  nausea,  vomiting,  or  other  ill  effects. 

Case  II. — Operation  for  abdominal  hernia.  The  patient,  a  woman, 
aged  thirty-seven  years,  weight  about  150  pounds,  was  given  one-quarter 
grain  of  morphin  and  one  one-hundred  and  fiftieth  grain  of  atropin 
thirty  minutes  before  the  operation,  hi  the  same  time,  a  solution  con- 
taining 10  grains  of  chloretone  and  4  drams  of  ether  with  an  equal 
amount  of  olive  oil  was  introduced  into  the  rectum.  Just  before  opera- 
tion a  75  per  cent  solution  was  given  to  the  patient  in  bed.  She  sank 
into  deep  surgical  narcosis  before  the  full  amount  (8  ounces)  was  intro- 
duced. A  slight  cyanosis  indicated  an  overdose,  therefore  three  and  a 
half  ounces  of  the  mixture  was  drawn  off,  as  the  patient  was  placed  upon 
the  operating  table.  The  relaxation  in  this  instance  was  perfect;  pulse 
and  respiration  were  about  normal.  The  patient  slept  for  six  hours  after 
the  operation  and  awoke  without  nausea  or  vomiting. 

This  six-hour  sleep  was  prior  to  our  discovery  that  practically  the 
entire  unused  amount  could  be  syphoned  off  by  massaging  directly  over 
the  colon  from  right  to  left  as  the  lower  bowel  is  irrigated. 

Case  III. — Private  patient ;  excision  of  the  tongue,  floor  of  the  mouth 
and  glands  of  the  neck.  On  account  of  adhesions  and  abnormalities  re- 
sulting from  a  cancerous  growth,  this  operation  lasted  nearly  three  hours. 
The  patient  was  a  man  of  about  forty-seven  years,  weighing  about  160 
pounds.  He  was  given  one-quarter  grain  of  morphin  with  one  one-hun- 
dred and  fiftieth  grain  of  atropin  hypodermatically,  half  an  hour  before 
the  operation,  and  ten  grains  of  chloretone  in  a  suppository  at  the  same 
time.  Eight  ounces  of  a  75  per  cent  mixture  of  oil  and  ether  were  ad- 
ministered. The  patient  dropped  to  sleep  almost  immediately.  At  the 
end  of  one  hour  the  pulse  was  full  and  regular,  but  there  was  stertor, 
which  .perceptibly  increased  until  respiration  ceased  for  three  minutes. 
At  the  commencement  of  stertor,  the  cut-off  in  the  rectal  tu,be  should 
have  been  removed  and  the  residual  mixture  allowed  to  drain  off.  This 
would  have  effectually  prevented  the  respiratory  arrest.  The  rectum  was 
washed  out  with  cold  water  and  as  much  as  possible  of  the  mixture  was 
withdrawn.  Eespiration  recommenced  without  anything  else  being  done, 
and  the  operation  was  continued  and  completed  without  further  inter- 
ruption. When  the  patient  was  returned  to  bed  the  pulse  was  72 ;  respira- 
tion, normal.  Eecovery  was  uneventful,  with  no  nausea  or  diarrhea 
following. 

Case  IV. — Boy,  aged  ten  years ;  operation  for  hydrocele  and  circum- 
cision.    One-twelfth  grain  sulphate  of  morphin  was  given  hypodermati- 


ANESTHESIA  BY  COLONIC  ABSORPTION   OF   ETHER      465 

cally  thirty  minutes  before  the  operation,  and  a  five-grain  cliloretone 
suppository  at  the  same  time;  between  75  and  100  c.  c.  of  a  75  per  cent 
mixture  was  introduced  very  slowly,  the  patient  falling  asleep  before  the 
full  amount  was  introduced,  sleeping  quietly  through  the  operation,  and 
making  an  uneventful  recovery. 

In  children  from  two  to  eight  years  of  age,  a  fifty  or  fifty-five  per 
cent  solution  of  ether  in  olive  oil  has  been  easily  retained,  without  any 
preliminary  medication,  and  has  been  followed  by  satisfactory  anes- 
thesia in  ten  to  twenty  minutes.  The  low  percentage  absorbed  by  chil- 
dren is  contrary  to  our  laboratory  experiments,  as  the  oil  does  not  part 
with  the  ether  in  fifty  per  cent  solutions  in  a  test  tube  placed  in  a  water 
bath  at  the  temperature  of  the  body.  The  difference  in  the  power  of  ab- 
sorption from  the  lower  bowel  in  children  and  adults  would  satisfactorily 
explain  this.  In  adults,  eight  ounces  of  ether,  with  an  equal  amount  of 
oil,  was  placed  in  the  rectum  with  no  anesthetic  effect  whatever. 

Case  V. — In  a  girl,  nine  years  of  age,  100  c.  c.  of  a  75  per  cent  solu- 
tion was  given  with  no  preliminary  medication.  The  child  complained 
slightly  as  the  mixture  was  administered.  The  operation  was  for 
adenoids  and  enlarged  tonsils,  and  the  relaxation  Avas  perfect.  The  child 
was  able  to  leave  the  hospital  five  hours  later. 

The  Sims  Position. — Case  VI. — At  the  commencement  of  the 
series,  two  patients  were  anesthetized  at  Eoosevelt  Hospital.  In  each 
instance,  unpleasant  symptoms  occurred  on  the  introduction  of  the  an- 
esthetic, and  in  each  a  supplementary  anesthetic  was  required.  These  pa- 
tients received  the  anesthetic  in  the  dorsal  position,  which  has  since  been 
abandoned  for  the  Sims  posture. 

EEGULATiO]sr  OF  DosAGE. — Case  VII. — A  woman,  aged  thirty-eight, 
weighing  125  pounds,  was  operated  upon  for  carcinoma  of  the  breast. 
The  patient  was  given  one-sixth  of  a  grain  of  morphin,  and  one  one-hun- 
dredth of  a  grain  of  atropin  hypodermatically.  Five  grains  of  chlore- 
tone,  dissolved  in  two  drams  of  ether  and  mixed  with  two  drams  of  olive 
oil,  were  introduced  into  the  rectum  thirty  minutes  before  the  opera- 
tion. Eight  ounces  of  a  75  per  cent  mixture  were  introduced  into  the 
rectum  in  six  minutes'  time.  The  patient  was  in  surgical  anesthesia 
four  minutes  after  the  total  mixture  had  been  introduced.  Three  ounces 
were  draAvn  off  during  the  operation,  as  the  patient  seemed  to  be  too 
deeply  narcotized.  The  resultant  anesthesia  Avas  perfect  in  every  re- 
spect, the  patient  breathing  quietly  as  in  natural  sleep  during  the  entire 
time  of  the  operation.  An  uneventful  recovery  with  no  nausea  or  vom- 
iting folloAved.    Blood  and  urine  analyses  proved  negative. 

Case  VIII. — In  this  instance  the  patient  received  one-quarter  grain 

of  morphin  with  one  one-hundredth  grain  of  atropin  hypodermatically 

'  thirty  minutes  before  the  operation.     No  suppository  was  used,  and  the 

patient  complained  slightly  of  discomfort  in  the  rectum  as  the  mixture 


466  ANESTHESIA 

was  introduced.  The  resultant  anesthesia  was  perfect  in  every  particular ; 
pulse  and  respiration  were  normal,  and  prompt  recovery  without  any 
unpleasant  after-effects  followed.  This  patient  who  had  been  operated 
upon  twice  previously  under  inhalation  methods,  and  who  was  al)le  to 
make  an  intelligent  comparison,  stated  that,  if  compelled  to  undergo 
another  operation,  the  oil-ether  would  he  the  choice  of  methods. 

Comparison  with  Other  Methods. — In  Part  I  of  this  chapter,  Sutton 
compares  ether-vapor  colonic  anesthesia  with  other  methods.  It  only 
remains  to  compare  oil-ether  colonic  and  ether-vapor  colonic  anesthesia. 
We  can  do  this  effectively  owing  to  the  very  careful  records  kept  by 
Sutton  and  full  records  of  over  500  oil-ether  anesthesias  administered  in 
iSTew  York  City  by  the  senior  author  and  others. 

(1)  One  of  the  greatest  advantages  of  the  method  is  that  the  anes- 
thetic can  be  administered  to  the  patients  in  bed  without  their  knowl- 
edge, thus  fulfilling  many  principles  of  anoci-association  as  enunciated 
by  Crile.  (2)  In  over  95  per  cent  of  cases  there  have  been  no  eructa- 
tions of  gas  during  anesthesia.  This  is  probably  due  to  the  pressure  in 
the  intestine  never  being  as  high  as  20  mm.  (3)  When  the  patient  has 
been  in  fair  condition,  there  has  been  not  a  single  instance  of  colitis, 
bloody  stools,  or  blood-streaked  returns.  (4)  The  oil-ether  narcosis  is 
evenly  maintained  automatically.  (5)  Postoperative  vomiting,  nausea, 
and  gas  pains  are  reduced  to  a  negligible  quantity.  (6)  The  patient 
recovers  consciousness  in  an  analgesic  state. 

Adverse  criticisms  upon  the  method  have  been  made  by  Luke  and 
Coburn,  but  evidently  their  technique  differed  from  that  outlined  by  the 
senior  author,  and  followed  by  him  and  others  with  satisfaction. 

Contra-indications. —  (a)  Whenever  ether  is  contra-indicated  except 
when  the  patient  has  been  ill  from  a  previous  etherization.  Here  it  can 
be  given  with  impunity.  In  bronchitis  and  asthma,  (b)  Colitis,  hemor- 
rhoids, fistulse,  and  other  pathological  conditions  of  the  lower  bowel, 
(c)  When  the  patient  complains  of  considerable  rectal  pain  upon  the 
introduction  of  the  solution. 

Indications. —  (a)  Where  the  element  of  fear  is  in  evidence,  as  in 
goiter  and  similar  cases,  (b)  Obese  individuals  with  narrowed  air  pas- 
sages, (c)  For  bronchoscopy,  gastroscopy,  and  all  operations  upon  the 
respiratory  tract,  head,  neck,  and  chest. 

BIBLIOGEAPHY 

Gwathmey:  17th  Int.  Cong,  of  Medicine,  London,  1913  (sub-section 
VII  (b),  163)  ;  N.  Y.  Med.  Jour.,  Dec.  6,  1913,  Jan.  31,  1911,  and  March 
28,  1914;  Am.  Gen.  Surg.,  July,  1914,  268. 

Luke,  H.  C. :    Med.  Rec,  May  9,  1914. 

Coburn,  E.  C:  Jour.  Am.  Med.  Ass7i.,  Jan.  31,  1914,  364. 

Pate,  J.  C. :  Ga.  Med.  Assn.  Jour.,  Feb.,  1914. 


CHAPTEK    XII 

SEQUESTEATION     METHOD     OF     ANESTHESIA 

History. 
Technique. 

Indications  :    Brain  Surgery ;  Goiter. 
Contraindications. 

Modifications  in  the  Method:  Advantages;  Disadvantages;  Se- 
questration with  the  Upright  Position. 

History. — The  ancient  Assyrians  are  supposed  to  have  been  the  first 
to  attempt  anesthesia  by  limiting  the  blood  supply  to  the  brain  when 
circumcising  their  children.  The  procedure  was  revived  by  Valverdi  in 
Italy  early  in  the  seventeenth  century;  he  attempted  to  obtain  uncon- 
sciousness by  the  compression  of  the  blood  vessels  of  the  neck. 

This  method  of  inducing  the  anesthetic  state  has  been  used  for  so 
long  a  time  and  so  frequently  that  it  is  impossible  to  say  who  was  the 
originator.  Corning/  in  1880,  attempted  to  confine  the  blood  saturated 
with  an  anesthetic  for  a  long  period  in  contact  with  the  cerebral  ganglia 
by  pressure  applied  to  the  carotid  arteries,  his  object  being  to  intensify 
the  effects  of  the  anesthetic.  In  1887  he  reversed  this  procedure  ^  by 
cording  the  thighs  of  a  stout,  healthy  individual,  so  as  to  interrupt  both 
the  arterial  and  venous  circulation,  thereby  cutting  off  absolutely  this 
amount  of  blood  from  the  anesthetic.  He  reports  a  case  of  a  strong, 
vigorous  patient  operated  on  at  the  Manhattan  Eye  and  Ear  Hospital  in 
New  York  City,  whom  it  took  six  to  seven  minutes  to  anesthetize  with 
ether  on  a  previous  occasion.  With  this  method,  by  cutting  off  "one- 
third  of  the  man"  and  saturating  the  remaining  two-thirds  of  the  blood 
mass,  the  patient  was  anesthetized  in  three  minutes.  Webster  then  did 
an  iridectomy;  the  ligatures  were  removed,  and  the  patient  recovered 
from  the  effects  of  the  ether  instantly.  The  rapid  recovery  was  wit- 
nessed by  over  half  a  dozen  physicians.  Corning  states  that  if  he  had 
occasion  to  test  this  method  again  he  would  ligate  the  arms  as  well  as  the 
lower  limbs. 

*  Coming:     "Carotid  Compression,"  1882. 
2 Idem.:     N.  Y.  Med.  J.,  Oct.  22,  1887. 

467 


468  ANESTHESIA 

The  idea  of  Corning  in  employing  this  procedure  was  to  get  the  pa- 
tient under  the  anesthetic  quickly,  to  maintain  surgical  anesthesia  with  a 
minimum  amount  of  the  anesthetic,  and  to  insure  rapid  recovery  from 
the  anesthetic.  Corning  ^  was  acquainted  with  the  procedure  of  Parry, 
of  Bath,  who,-  in  1792,  used  compression  of  the  carotids  for  the  allevia- 
tion of  convulsive  disorders,  and  also  that  of  Blaud,  who,  in  1819,  used 
compression  of  the  carotids  for  cerebral  engorgements  of  various  kinds. 
Stroehlin  ^  also  suggested  that  tying  the  carotids  on  the  opposite  side  to 
which  a  convulsion  appeared  would  be  of  benefit. 

Webster  ^  further  elaborated  this  idea  by  suggesting  that  a  certain 
amount  of  blood  should  always  be  cut  off  from  the  body,  with  the  idea  of 
throwing  it  into  the  system  instantly  if  alarming  symptoms  such  as 
cyanosis  should  suddenly  occur. 

In  May,  1903,  Dawbarn  *  applied  this  method  to  brain  and  skull  sur- 
gery. This  method  is  now  known  as  '^sequestration  anesthesia."  Daw- 
barn  was  first  led  to  think  of  this  method  from  the  fact  that,  in  an  opera- 
tion upon  an  extremity,  care  is  always  taken  to  elevate  that  extremity 
and,  by  gravity  and  bandaging,  to  squeeze  out  all  the  blood  and  retain 
it  in  the  body  while  the  necessary  surgical  Work,  such  as  amputations,  is 
carried  on.  This  method  is  used  by  surgeons  the  world  over,  but  no 
one  attempted  to  avoid  hemorrhage  in  operating  upon  the  upper  trunk 
or  upper  extremities.  Dawbarn  suggested  saving  blood  by  reversing  this 
procedure  and  retaining  blood  in  the  extremities,  and  thereby  avoiding 
hemorrhage  at  the  seat  of  operation.  The  method  has  not  received  the 
attention  it  deserves,  and  its  merits  have  been  tested  by  comparatively 
few  up  to  this  time. 

Technique. — Dawbarn's  technique  is  as  follows :  "The  patient  is 
first  thoroughly  anesthetized  by  any  pulmonary  anesthetic.  A  towel  is 
then  folded  lengthwise  and  wrapped  about  each  thigh  very  close  to  the 
trunk,  and  upon  this  the  rubber  tube  is  tightened.  The  towel  serves  in 
a  measure  to  prevent  subsequent  discomfort  by  spreading  the  pressure 
over  a  wide  area.  The  degree  of  tightness  is  quickly  learned  by  practice. 
It  must  nearly  stop  the  venous,  but  not  the  arterial,  current.  The  limb 
grows  dusky  in  color,  and  there  is  also  an  obvious  swelling.  In  from  five 
to  ten  minutes  the  softened  pulse  will  indicate  that  you  are  ready  to  pro- 
ceed with  the  operation.  The  patient  is  now  placed  in  the  sitting  posture, 
and  the  operation  is  begun.  The  anesthetic  given  in  this  way  may  last 
from  fifteen  to  thirty  minutes.  In  about  fifteen  minutes  after  the  com- 
mencement of  the  anesthesia  the  cords  are  gradually  loosened,  and  the 

^Corning:      "Carotid   Compression  of  the  Brain  Arteries,"    1882. 

2  Stroehlin:      These  de  Paris,  1840,  No.  271. 

3  Webster:     JV.   Y.   Med.  J.,  Oct.  29,   1887. 

4  Dawbarn :  ' '  Sequestration  Anemia  in  Brain  and  Skull  Surgery, ' '  Ann. 
of  Surg.,  May,  1903. 


SEQUESTRATION    METHOD    OF    ANESTHESIA  469 

operation  is  continued,  depending  upon  the  anesthetic  effects  produced 
from  the  anemia  of  the  brain.  This  procedure  seems  to  be  perfectly  safe, 
for  if  any  untoward  symptoms  arise  they  can  be  immediately  rectified  by 
placing  the  patient  in  a  horizontal  or  Trendelenburg  position  and  loosen- 
ing the  cords,  when  the  brain  will  immediately  become  tilled  with  blood. 
The  pulse  is  tested  before  the  tourniquets  are  applied,  so  that  the  soften- 
ing and  lessening  of  tension  will  be  noticed.  Every  cut  vessel  spurts  less 
blood  than  would  otherwise  be  the  case.  The  limbs  corded  are  warmly 
wrapped  or  hot-water  bags  are  placed  about  them." 

Dawbarn  states  that  enough  blood  can  be  retained  in  the  limbs 
to  make  a  striking  difference  in  loss  of  blood  from  the  operative 
field,  and  to  constitute,  in  many  cases,  the  difference  between  life 
and  death,  or  shock  and  absence  of  shock,  in  a  gravely  severe  case. 
The  effect  is  to  increase  and  deepen  respiration,  the  same  as  if  the  patient 
were  bleeding  from  a  wound  instead  of  into  his  own  limbs.  The  cording 
may  be  done  with  a  conscious  patient  before  the  anesthetic  is  started,  in 
order  to  form  a  reserve  guard  of  pure  blood.  Dawbarn  advises  against 
going  to  extreme  limits,  and  states  that  should  a  tendency  toward  car- 
diac weakness  be  observed,  a  release  of  the  cordage  should  be  immediate, 
which  will  produce  a  distinct  improvement  in  both  the  force  and  number 
of  heart  beats.  There  is  no  case  on  record,  he  says,  where  absolute  stag- 
nation of  healthy  blood  in  a  healthy  limb  for  half  an  hour  has  been  fol- 
lowed by  gangrene.  He  prefers,  however,  to  limit  the  time  of  cordage  to 
fifteen  minutes.  His  technique  for  long  operations  is  to  tighten  the  cord 
in  such  a  way  that  a  small  amount  of  blood  is  continually  entering  and 
some  blood  escaping  into  the  trunk.  If,  at  any  time,  the  limb  grows 
excessively  swollen,  or  if  the  patient's  pulse  demands  a  change,  the  ten- 
sion is  lessened.  Dawbarn  has  constricted  all  four  extremities  in 
plethoric  individuals,  but  states  that  constricting  the  lower  limbs  at  the 
groin  is  sufficient.  The  blood  must  be  released  gradually.  He  gives  sev- 
eral illustrative  cases,  among  which  is  the  following: 

Case  I. — Excision  of  cerebellar  tumor.  Male,  age  60.  Ether  was  the 
initial  anesthetic  chosen.  A  glioma  was  removed.  Operation  lasted 
three-quarters  of  an  hour,  during  which  patient  took  no  more  anesthetic 
after  being  placed  in  the  sitting  posture.  Slept  quietly  and  without 
stertor.    Eecovery  was  without  incident. 

Indications. — Bkain"  Surgery.— When  the  sequestration  method  is 
employed,  a  striking  lowering  of  intracranial  pressure  occurs.  Where  a 
brain  tumor  is  to  be  operated  upon,  the  safety  is  greatly  increased  by 
thus  reducing  the  pressure. 

Goiter. — In  thyroidectomy  Wyeth  also  recommends  it. 

Contraindications. — Dawbarn  states  that  unhealthy  blood  or  blood 
vessels  are  contraindications,  as  the  damming  of  the  current  of  blood  by 
the  cording  would  then  become  an  exciting  cause  and  make  sequestration 


470  ANESTHESIA 

dangerous  from  venous  thrombosis  and  possible  subsequent  pulmonary 
embolism. 

Eecent  typhoid  fever,  any  septic  condition  of  the  blood,  puerperal 
sepsis,  chlorosis,  or  severe  anemia  of  any  kind,  the  presence  of  lime  salts 
in  excess,  atheroma  of  the  blood  vessels,  hypertension,  arteriosclerosis, 
and  leukemia  are  all  contraindications  to  its  use. 

Modifications  in  the  Method. — Where  it  is  necessary,  for  obvious 
reasons,  to  use  a  minimum  amount  of  the  anesthetic,  a  modification  of 
the  sequestration  method  without  cording  may  be  tried.  It  is  a  well- 
known  fact  that  patients  are  very  susceptible  to  changes  in  body  posi- 
tion while  under  an  anesthetic.  Toward  the  close  of  any  operation,  as 
the  surgeon  is  sewing  up  the  wound,  the  anesthetic  may  be  discontinued, 
provided  the  head  of  the  table  is  raised  in  order  to  keep  the  patient's  head 
well  elevated.  It  will  be  found  that  the  anesthesia  will  be  continued  for 
quite  a  while  longer  than  if  this  procedure  were  not  adopted.  It  is  also 
good  practice  to  keep  the  head  elevated  by  placing  pillows  under  it  as 
soon  as  the  patient  is  returned  to  bed.  This  not  only  facilitates  the  con- 
tinuance of  sleep,  but  it  allows  mucus  or  saliva  to  drain  away  from  the 
upper  respiratory  passages,  including  the  olfactory  nerve  endings, 
whereas  if  it  remained,  it  would  be  apt  to  cause  nausea  and  vomiting.  In 
recommending  this  modification,  it  is  taken  for  granted  that  the  anes- 
thesia has  been  considerably  lightened  and  that  most  of  the  reflexes  are 
present  at  this  time. 

The  sequestration  method  is  especially  valuable  in  connection  with 
Eose's  chair  table  for  the  bloodless  removal  of  adenoids  and  tonsils. 

One  of  the  authors  gave  the  anesthetic  for  Professor  Dawbarn  in  one 
case  in  which  this  method  was  employed.  After  inducing  anesthesia,  the 
thighs  were  corded,  and  the  patient  was  placed  in  the  sitting  position 
upon  the  operating  table.  Anesthesia,  induced  in  this  way,  lasted  from 
ten  to  fifteen  minutes,  when  a  second  application  of  the  anesthetic  was 
needed,  and  the  patient  was  again  placed  in  position  for  operation.  An 
improvement  upon  this  procedure,  of  course,  would  be  a  continuation  of 
the  anesthetic  by  the  vapor  method  in  small  amounts,  as  the  operation 
could  then  be  continued  without  moving  the  patient. 

Advantages. — Dawbarn  sums  up  the  advantages  of  this  method  as 
follows:  (1)  The  diminution  in  amount  of  the  anesthetic  needed;  (2) 
ease  of  control  of  hemorrhage;  (3)  shortening  of  the  operation,  because 
of  a  dry  field;  (4)  lessened  danger  of  sudden  death  from  pressure  upon 
the  respiratory  centers;  (5)  increased  depth  and  frequency  of  breathing; 
(6)  in  brain  operations  more  space  between  brain  and  brain  case,  en- 
abling the  operator  to  work  between  them  in  removing  old  clots  requir- 
ing curettage  or  the  separation  of  adhesions,  etc.,  without  risk  of  lacera- 
tion of  the  brain  surface. 


SEQUESTRATION    METHOD    OF    ANESTHESIA  471 

Zoeppritz  ^  reports  112  operations,  commenting  favorably  upon  its 
effect  upon  narcosis,  and  states  there  were  no  ill  effects  and  especially  no 
post-operative  vomiting. 

Wyeth  -  states :  "It  has  been  demonstrated  that  prolonged  and  satis- 
factory narcosis  can  be  induced  and  maintained  by  the  combination  with 
ether  and  morphia  hypodermically,  and  nitrous  oxid  and  oxygen,  together 
with  the  mechanical  induction  of  cerebral  anemia  by  Professor  Daw- 
barn's  method  of  temporarily  confining  a  good  portion  of  the  volume  of 
the  blood  in  the  extremities.  In  expert  hands,  after  the  anesthetic  has 
been  once  removed,  operations  lasting  one  hour  or  more  have  been  per- 
formed with  the  anesthetic  discontinued,  the  patient  seemingly  in  natural 
sleep."  Wyeth  prefers  this  method  to  rectal  anesthesia,  also  for  pene- 
trating wounds  of  the  skin  and  air  passages,  for  the  removal  of  the  caro- 
tid gland,  and  for  formidable  operations  about  the  mouth  and  ulcers  of 
the  tongue.  In  operations  upon  the  thyroid  body,  he  states  that  it  di- 
minishes the  blood  pressure  in  the  operative  field. 

The  technique  recommended  by  Klapp,^  who  uses  ether  by  preference, 
is  as  follows :  The  two  thighs,  not  all  four  extremities  (as  in  the  method 
of  Delageniere),  are  tied  near  their  insertions  at  the  trunk,  beginning 
with  the  application  of  a  strong  compression  bandage  on  each  leg,  so  as 
to  collect  a  certain  amount  of  blood  in  the  limb.  At  the  end  of  a  few 
minutes  a  complete  constriction,  of  the  same  degree  as  an  Esmarch 
ischemia  bandage,  is  applied  above  the  congestion  bandage.  The  narcosis 
is  then  begun. 

Klapp  prefers  not  to  begin  with  ether-drop  narcosis,  but  with  a  sort 
of  ether-intoxication  (aether  rausch).  (See  p.  209.)  This,  or  a  brief 
narcosis  with  ether,  is  sufficient  for  small  interventions.  In  prolonged 
narcosis  it  is  recommended  that  the  lesser  circulation  be  promptly  satu- 
rated with  the  ether,  the  administration  being  then  continued  with  ether- 
drop  narcosis. 

The  influence  of  the  diminished  circulation,  according  to  Klapp,  is 
much  more  evident  when  chloroform  is  employed.  The  constriction  is 
preferably  made  by  means  of  a  wide  Martin  rubber  bandage,  which  is 
stronger  and  more  elastic  than  the  woven  Esmarch  ischemia  bandage. 

Klapp  refers  to  the  animal  experimentation  of  Ziegner,  which  con- 
firmed the  accuracy  of  Coming's  idea.  He  also  mentions  the  work  of 
Hormaniij  in  Doderlein's  clinic,  who  established  the  figures  of  the  quanti- 
tative requirement  of  anesthetics,  with  the  diminished  as  well  as  the  im- 
diminished  circulation. 

'Zoeppritz:     Mitteil.  a.  d.  Grenzgel.,  1911,  3. 
'^  Wyeth:     "Surgery,"  16. 

'  Klapp,  R. :  "  Ueber  die  Narkose  bei  kiinstlich  verkleinertem  Kreislauf . ' ' 
Therapeutische  Monat.,  Jan.,  1910,  14. 


472  ANESTHESIA 

Delageniere  ^  accomplished  this  exclusion  by  means  of  elastic  band- 
ages applied  to  the  bases  of  the  limbs,  in  such  manner  as  to  arrest  both 
the  arterial  and  the  venous  circulation.  Not  only  the  blood  contained 
in  the  limbs,  but  the  tissues  of  the  limbs  as  well  are  excluded,  so  that 
they  do  not  become  charged  with  the  anesthetic  during  the  narcosis. 
When  the  bandages  are  removed  the  sequestrated  blood  and  tissues  help 
to  bring  about,  automatically,  a  rapid  dilution  of  the  toxic  impregnation 
of  the  medulla  and  the  mass  of  blood.  This  dilution  of  the  blood  im- 
pregnated with  the  anesthetic  is  accomplished  by  the  excluded  blood, 
which  contains  no  anesthetic,  and  by  the  absorption  of  a  portion  of  the 
anesthetic  contained  in  the  non-excluded  blood,  through  the  muscles  and 
other  tissues  which  have  been  excluded. 

General  narcosis,  with  reduced  circulation,  was  carried  out  in  Dela- 
geniere's  clinical  service  and  in  the  hospital,  1,144  times  with  chloroform 
and  35  times  with  ether.  The  results,  advantages,  and  disadvantages 
noted  are  summarized  as  follows : 

Advantages. — The  narcosis  is  more  rapid.  The  average  time  re- 
quired to  obtain  sleep  is  only  five  minutes.  The  sleep  is  better,  and,  as 
the  patient  breathes  more  rapidly,  the  respiration  is  more  easily  watched. 

Less  chloroform  is  needed  to  produce  sleep,  and  especially  to  maintain 
it,  so  that  there  is  a  saving  of  about  fifty  per  cent. 

AwaTcening  is  more  rapid.  On  an  average,  the  patient  awakes  at  the 
end  of  ten  minutes,  instead  of  thirty,  as  in  ordinary  narcosis.  Frequently 
awakening  is  instantaneous  upon  removal  of  the  bands. 

Post-operative  organic  disturbances  are  diminished.  This  is  perhaps 
the  greatest  advantage  of  the  method.  The  alterative  action  of  the  anes- 
thetic is  actually  diminished,  as  the  toxic  agent  is  taken  in  smaller  quan- 
tities and  is  much  more  rapidly  eliminated.  It  is  therefore  a  foregone 
conclusion  that  all  the  viscera  must  be  benefited  by  the  method,  accord- 
ing to  Delageniere.  As  a  matter  of  fact,  vomiting  is  less  common  and 
less  abundant.  Post-operative  icterus  and  subicterus  are  much  less  fre- 
quent and  less  serious. 

Post-chloroformic  albuminuria  practically  ceases  to  exist,  so  that  the 
sequestration  method  to  a  certain  extent  prevents  the  danger  of  post- 
operative anemia. 

Respiratory  failure  is  efficiently  controlled  through  removal  of  one 
or  several  bandages.  The  excluded  blood  returns  into  the  circulation, 
and,  as  it  is  at  the  zero  point  of  chloroform  concentration,  it  accomplishes 
a  favorable  dilution,  relieving  the  bulb.  Moreover,  having  become  loaded 
with  carbon  dioxid  during  the  period  of  exclusion,  it  acts  upon  the  res- 
piratory center,  stimulating  it. 

^  Delageniere :  "  De  1  'anesthesie  generale  avec  circulation,  reduite  ou  ex- 
clusion des  quatre  membres  dans  I'anesthesie  generale."  Bull,  de  I' Acad,  de 
Med.,  July  25,  1911,  88. 


SEQUESTRATION    METHOD    OF    ANESTHESIA  473 

Disadvantages. — The  disadvantages  are  inconsiderable.  They  con- 
sist in  tingling  sensations  in  the  excluded  limbs,  lasting  a  few  hours;  or 
small  cutaneous  ecchymoses,  sometimes  slight  stiffness,  or  even  mild 
paresis.  Phlebitic  complications  in  the  lower  extremities  are  perhaps 
more  apt  to  supervene  with  this  method  than  with  the  ordinary  method. 
Among  his  1,179  cases,  Delageniere  observed  four  cases  of  post-operative 
phlebitis  of  the  lower  limbs.  Three  of  these  four  cases  concerned  gyne- 
cological affections,  so  that  the  trouble  may  have  been  referable  to  pres- 
sure from  leg  holders,  or  the  border  of  the  inclined  plane,  upon  the  veins 
in  which  the  circulation  is  more  than  retarded  by  the  application  of  the 
bandages. 

As  contraindications,  Delageniere  admits  only  certain  cases  of  myo- 
carditis, or  valvular  lesions,  and  certain  general  infections. 

As  absolute  indications,  he  considers  all  diseases  of  the  kidneys  and 
of  the  liver,  particularly  alcoholism. 

Sequestration  with  the  Upright  Position. — French  ^  is  probably  the 
first  surgeon  to  use  the  sequestration  method  with  the  upright  position 
systematically.     We  quote  voluminously  from  his  article: 

"The  method  consists  in  anesthetizing  the  patient  and  at  the  same 
time  producing  congestive  hyperemia  of  the  limbs  by  means  of  inflated 
blood  pressure  cuffs  about  the  thighs  and  arms  (Fig.  180)  or  thighs 
alone,  to  still  further  reduce  the  amount  of  blood  in  the  heart.  After 
beginning  with  a  light  pressure  of  the  cuffs  upon  the  thighs  alone,  which 
was  afterward  in  other  cases  gradually  increased,  we  attained  at  the 
end  of  the  first  operating  clinic,  in  which  these  tests  were  made,  as  high 
a  degree  of  pressure  as  we  are  using  now;  but  it  was  not  until  a  later 
occasion  that  we  felt  justified  in  employing  the  inflated  rings  upon  all 
four  of  the  limbs  at  the  same  time.  In  the  first  case  in  which  the  trial 
was  made  it  was  found  that  there  was  a  marked  diminution  in  the 
amount  of  blood  lost  and  also  that  the  anesthesia  was  prolonged  after 
removing  the  inhaler  at  the  beginning  of  the  operation,  to  a  much 
greater  extent  than  we  had  ever. known  it  to  be  by  any  other  method. 
And  with  very  few  exceptions — in  which  the  conditions  were  unfavorable 
— the  same  experience  has  been  repeated  in  every  case  in  which  the 
method  has  been  used. 

"The  sequestration  method,  in  association  with  the  upright  position 
which  has  been  carried  out  in  fifty-eight  cases,  reduces  still  further  the 
amount  of  anesthetic  required,  and  still  further  the  loss  of  blood.  That 
the  amount  of  the  anesthetic  is  reduced  is  proved  by  the  fact  that  full 
anesthesia  has  often  been  maintained  for  fifteen  or  twenty  minutes  after 
the  body  was  brought  to  the  upright  position  and  the  inhaler  removed. 
Indeed,  after  beginning  the  operation,  in  most  cases  in  which  this  method 

'  French,  Thomas  R. :  "  Nitrous  Oxid,  Essence  of  Orange,  Ether  and  Se- 
questration in  General  Anesthesia."     N.  Y.  Med.  J.,  May  24,  1913. 


474 


ANESTHESIA 


of  anesthesia  has  been  used,  except  for  his  assistance  in  other  ways,  we 
have  been  able  to  dispense  with  the  services  of  the  anesthetist,  which  is 
only  another  way  of  saying  that  during  relatively  short  operations  the 
further  administration  of  the  anesthetic  has  not  been  needed. 

"In  quite  'a  number  of  cases  the  quantity  of  blood  lost  during  the 
removal  of  adenoid  growths  and  the  faucial  tonsils  (and  we  use  these 
operations  in  illustration  because  the  amount  of  blood  usually  lost  in 
them  is  so  well  known),  while  sequestration  was  being  applied,  was  be- 


FiG.  181. — Sequestration  Method  as  Used  in  French's  Clinic.     White  cuffs  in  place 
on  arms;  cuffs  being  placed  on  thighs  by  nurse. 

lieved  to  be  less  than  a  drachm.  In  many  of  the  cases  the  blood  loss,  in 
operations  in  either  the  nose  or  throat,  could  only  be  measured  by  the 
appearance  of  the  sponges;  in  most  cases  it  was  but  slightly  in  excess 
of  that,  and  in  none  was  the  bleeding  as  free  as  in  the  average  case,  of 
similar  operative  character,  under  the  older  methods  of  anesthesia.  It 
may,  therefore,  be  said  that  the  average  blood  loss  with  the  sequestra- 
tion method,  whether  applied  to  arms  and  legs  or  legs  alone,  is  far  be- 
low that  which  occurs  without  sequestration,  and  that  certain  operations, 
which  with  the  ordinary  methods  are  usually  attended  with  a  large  loss 
of  blood,  may  be  rendered  practically  bloodless  by  the  use  of  the  seques- 
tration upright  position. 


SEQUESTRATION    METHOD    OF    ANESTHESIA  475 

"We  had  thought  of  the  possibility  of  secondary  hemorrhage  being 
occasioned  by  the  sudden  release  of  the  locked-up  quantity  of  blood  at 
practically  the  same  moment  that  the  body  was  returned  to  tlie  lujri- 
zontal  position,  but,  happily,  there  does  not  seem  to  be  reason  for  appre- 
hension on  that  score,  for,  after  the  operations  were  finished  and  the 
bleeding  arrested,  there  was  no  further  hemorrhage  in  this  series  of 
cases. 

"The  amount  of  pressure  made  with  the  cuffs  varied  from  that  needed 
to  effect  a  slight  diminution  in,  to  that  needed  to  produce  a  complete 
obliteration  of,  the  pulse  in  the  anterior  tibial  and  the  radial  arteries,  and 
we  feared  that  the  firm  pressure  required  to  cause  an  obliteration  of  the 
pulse  might  produce  injury  to  nervous  structures;  but  in  none  of  the 
cases  could  any  history  of  untoward  after-effects  be  elicited.  It  is  quite 
possible,  perhaps  even  probable,  that  this  can  be  explained  by  the  com- 
paratively wide  distribution  of  the  pressure  and  the  fact  that  it  was 
made  with  a  flexible  air  bag.  The  pressure  was  maintained  in  all  but  the 
earliest  cases,  from  the  end  of  the  induction  stage  of  anesthesia  to  the 
time  of  completing  the  operation. 

"The  only  patient  operated  upon  since  the  series  of  the  tests  of  se- 
questration was  begun,  who  presented  symptoms  after  operation  which 
suggested  a  previous  injury  to  the  legs,  was  a  very  delicate  child  of  five 
years,  about  whose  thighs  the  cuffs  were  applied,  but  which  were  not 
inflated.  As  the  patient  was  an  extremely  delicate  piece  of  human  mech- 
anism, and  the  test  was  in  its  earliest  stage,  we  regarded  it  as  unwise 
to  expose  it  to  what  might  seem  to  be  something  of  a  risk.  It  would, 
therefore,  appear  that  we  just  escaped  the  reputation  of  having  had  one 
harmful  effect  from  this  method  of  anesthesia. 

"To  be  able  to  administer  a  smaller  quantity  of  an  anesthetic  and 
obtain  a  full  anesthesia;  to  see  the  patient  enter  the  anesthetized  state 
without  the  stage  of  excitement ;  to  be  able  to  stop  the  administration  of 
the  anesthetic  when  the  body  is  brought  to  the  upright  position  and  yet 
have  the  anesthesia  prolonged  enough  to  permit  relatively  long  operations 
to  be  performed ;  to  secure  a  greatly  lessened  loss  of  blood ;  and  to  insure 
a  reduction  in,  and  in  many  cases  an  almost  complete  abolition  of,  the 
disagreeable  a:?ter-effects  is,  to  say  the  least,  something  of  a  gain,  and  in 
a  large  proportion  of  cases,  with  the  cooperation  of  a  skillful  anesthetist, 
all  of  these  results  are  obtainable." 


CHAPTEE    XIII 

LOCAL    ANESTHESIA    AND     INTEAVENOUS    ANESTHESIA 

PAET    I 
LOCAL  ANESTHESIA 

James  F.  Mitchell,  M.D. 

History:  Adrenalin;  Coeain  Substitutes;  Arterial  Injection;  Ex- 
planation of  Poisonous  Action  of  Coeain;  Preparation  of  Solutions; 
Sterilizing  the  Solutions;  Novocain;  Urea  and  Quinin  Hydrochlorid ; 
Syringes ;  Indications  and  Scope  of  Local  Anesthesia ;  Local  Versus  Gen- 
eral Anesthesia;  Mortality;  General  Preparation  and  Technique;  De- 
tails as  to  Comfort  of  Patient;  After-treatment;  Healing;  Combination 
of  Local  and  General  Anesthesia. 

Methods  :  Surface  Application ;  Infiltration ;  The  Eegional  Method ; 
Venous  Anesthesia;  Arterial  Anesthesia. 

Special  Application:  Skin;  Head  and  Neck;  Face;  Ear;  Nose 
and  Accessory  Sinuses,  Tonsils;  Eye;  Neck;  Tracheotomy;  Larynx; 
Thyroid;  Thorax  and  Breast;  The  Extremities;  Genito-urinary  System; 
Circumcision;  Eectum;  Gynecology;  Abdomen;  Inguinal  Hernia. 

HISTORY 

The  desire  to  alleviate  pain  is  as  old  as  man;  its  fulfillment  has 
had  to  wait  long  (Braun).  Previous  to  the  introduction  of  coeain 
but  little  had  been  accomplished  in  attempting  to  produce  local  anes- 
thesia for  surgical  operations.  The  Egyptians  were  said  to  have  pos- 
sessed certain  applications  for  this  purpose,  but  investigation  has  shown 
them  to  have  been  more  superstition  than  actual  fact. 

Compression  of  nerve  trunks  was  probably  the  earliest  method  to  be 
of  any  real  service.  Originating  in  antiquity,  it  was  practiced  by  the 
Arabs,  revived  by  Pare  in  the  seventeenth  century,  and  throughout  suc- 
ceeding ages  one  sees  it  cropping  out  anew  in  some  special  tourniquet  or 
pressure  pad,  only  to  be  again  abandoned.    It  survives  now  in  the  form  of 

476 


LOCAL  ANESTHESIA  477 

the  Esmarch  elastic  bandage,  whicli,  it  is  true,  will  produce  anesthesia 
of  the  distal  part  of  a  limb.  The  uncertainty  of  the  anesthesia  and  the 
length  of  time  necessary  to  produce  it,  the  actual  pain  of  the  pressure 
itself,  and  the  danger  of  gangrene  and  motor  paralysis  render  it 
unsafe  and  impracticable.  In  slight  operations  on  the  fingers  and  toes, 
it  is  often  bearable  and  quite  satisfactory,  and,  in  lessening  the  pain  of 
the  first  introduction  of  a  hypodermic  needle,  firm  digital  compression  of 
the  skin  is  of  material  assistance. 

An  Italian  surgeon,  Severino,  through  his  pupil,  Thomas  Bartholinus, 
in  the  sixteenth  century,  first  called  attention  to  the  application  of  cold 
locally  as  a  means  of  reducing  sensibility.  Three  centuries  later  it  was 
again  brought  into  practice  by  the  animal  experiments  of  John  Hunter, 
and  in  1807  Larrey,  Napoleon's  surgeon,  reported  that  in  amputations 
done  on  the  field  of  battle  at  very  low  temperatures  ( — 19°  C.)  the  sensi- 
bility of  the  extremities  was  completely  abolished.  In  1886  Sir  Benjamin 
Ward  Eichardson,  an  enthusiastic  worker  for  the  attainment  of  local 
anesthesia,  placed  this  method  on  a  practical  basis  by  the  invention  of 
the  ether  spray.  This  survives  to-day  as  the  ethyl  chlorid  spray,  which  is 
more  or  less  widely  used  for  the  performance  of  many  minor  procedures. 
Ethyl  chlorid,  as  a  freezing  agent,  was  described  by  Rothenstein  in  1867 
and  reintroduced  by  Eedard  in  1891  as  a  local  anesthetic.  It  is  an  in- 
flammable gas,  but  is  dispensed  commercially  compressed  into  a  colorless 
fluid  contained  in  a  cylinder,  the  nozzle  of  which  is  provided  with  a  stop- 
cock. Boiling  at  13°  C,  it  evaporates  at  once  at  ordinary  room  tempera- 
ture. The  stopcock  is  opened  and  the  tube  held  at  a  distance  of  several 
inches,  allowing  the  spray  to  play  upon  the  part  to  be  anesthetized  until 
it  is  white  and  frozen.  The  freezing  process  acts  as  a  terminal  anes- 
thetic, and  is  complete  in  a  few  seconds.  Applied  to  nerve  trunks,  freez- 
ing will  completely  block  their  conduction  of  sensation;  but  this  is  ac- 
complished only  at  the  expense  of  great  pain.  Prolonged  or  extensive 
freezing  is  apt  to  cause  sloughing,  and  even  in  limited  areas  the  return 
of  tissues  to  their  normal  state  is  very  painful.  Its  field  of  usefulness  is 
therefore  narrow,  and  in  nearly  all  cases  the  injection  of  some  anesthetiz- 
ing drug  is  much"  to  be  preferred.  Both  pressure  and  cold,  however,  act 
as  aids  in  intensifying  and  prolonging  the  action  of  injected  drugs. 

Besides  these  physical  means — pressure  and  cold — ancient  medical 
literature  is  replete  with  instances  of  drugs  claimed  to  produce  local  loss 
of  sensation.  Mandragora,  aconite,  and  a  host  of  others  have  been  ex- 
ploited as  applications  to  mucous  membrane  or  unbroken  skin.  All  have 
been  discarded  as  practically  worthless. 

Electricity  came  in  for  its  trial  as  a  local  anesthetic,  and  as  a  means 
of  carrying  in  drugs  was  at  one  time  extensively  employed.  The  efl^ect 
was  probably  more  that  of  suggestion  than  of  actual  medication. 

Local  anesthesia  through  the  physiological  action  of  special  drugs  was 


478  ANESTHESIA 

made  possible  in  1853  by  Alexander  Wood,  who  introduced  the  hypo- 
dermic syringe,  and  thus  offered  a  new  means  of  applying  solutions  to 
sensitive  parts.  Wood  began  at  once  with  the  injection  of  morphin  in 
the  neighborhood  of  nerve  trunks  for  the  relief  of  neuralgia.  Many  cases 
were  reported  in  which  local  anesthesia  was  thus  produced.  The  results 
obtained  were  due  to  the  general  rather  than  to  the  local  action  of  the 
morphin.  Many  other  substances  were  tried,  but  none  was  found  satis- 
factory until  cocain  was  introduced  in  1884  by  Koller.  With  it  begins 
the  development  of  modern  local  anesthesia.  The  earliest  clinical  demon- 
strations of  the  value  of  cocain  were  made  by  Halsted  (1884)  and  Corn- 
ing (1885).  Even  at  this  early  stage,  Halsted  pointed  out  many  of  the 
essential  points,  and  emphasized  the  importance  of  intradermal  injection 
and  the  efficacy  of  very  dilute  solutions.  Hall  and  Halsted  also  demon- 
strated the  fact  that  injection  of  a  nerve  trunk  in  any  part  of  its  course  is 
followed  by  a  sensory  paralysis  in  its  entire  peripheral  distribution,  thus 
paving  the  way  for  the  neuroregional  method,  which  later  was  developed 
by  Crile,  Gushing,  and  Matas.  To  Eeclus  and  Schleich  is  due  the  credit 
of  lessening  the  danger  of  poisoning  by  reducing  the  strength  of  solu- 
tions. 

Adrenalin. — The  demonstration  of  the  value  of  adrenalin  as  an  addi- 
tion to  solutions  of  cocain  and  other  anesthetics,  as  brought  out  by 
Elsberg,  Barker,  and  Braun,  was  an  enormous  step  forward.  Adrenalin 
was  first  prepared  in  1901  in  pure  form.  It  is  a  powerful  vasocon- 
strictor, and  in  a  dilution  of  1 :  1,000,000  will  produce  local  ischemia.  It 
takes  the  place  of  the  physical  aids,  cold  and  pressure,  and  by  hindering 
absorption  acts  as  a  valuable  safeguard  against  poisoning.  It  can  be 
added  to  solutions  drop  by  drop  in  the  commercial  strength  (1:  1,000), 
or  may  be  prepared  with  the  anesthetizing  drug  in  tablet  form. 

Cocain  Substitutes. — Many  substitutes  for  cocain  have  been  intro- 
duced in  recent  years,  chiefly  because  of  their  lesser  toxicity.  Few  of 
these  have  become  popular,  eucain  and  novocain  being  the  chief  survivors. 
Solutions  of  quini'ii  have  been  quite  extensively  used  in  some  quarters, 
it  being  claimed  for  them  that  their  toxicity  is  almost  nothing  and  the 
anesthesia  produced  by  them  of  long  duration. 

Arterial  Injection. — In  1908  Bier  suggested  a  new  method  of  pro- 
ducing local  anesthesia  in  the  limbs  by  the  injection  of  novocain  into  a 
vein,  and  in  1909  Goyanes  modified  this  method  by  making  the  injec- 
tion directly  into  an  exposed  artery  instead  of  a  vein.  These  procedures 
represent  the  newest  departures  in  local  anesthesia,  and  will  undoubt- 
edly prove  to  be  of  great  value  and  wide  application. 

Explanation  of  Poisonous  Action  of  Cocain. — Cocain,  the  first  drug 
to  make  local  anesthesia  a  practical  possibility,  has  been  unduly  criti- 
cized as  to  the  danger  of  poisoning.  This  was  due  at  first  to  the  strong 
solution  used  and  later  to  faulty  technique,  too  rapid  injectioUj  or  imper- 


LOCAL  ANESTHESIA  479 

feet  eontrol  of  the  eirculation.  Cocain  is  a  protoplasmic  poison,  form- 
ing with  protoplasm  an  unstable  combination  which  breaks  down  slowly, 
after  which  the  tissues  return  to  their  normal  condition  and  resume  their 
normal  function.  That  part  which  has  entered  into  this  combination 
and  has  exerted  its  anesthetizing  power  cannot  be  absorbed;  therefore 
poisoning  can  be  due  only  to  absorption  of  the  excess,  which  the  tissues 
are  unable  to  take  up.  The  toxic  dose  varies  with  the  concentration  of 
the  solution  and  its  method  of  application.  Subcutaneously  it  is  stated 
to  be  50  mg.,  intravenously  2  mg.,  and  intra-arterially  ten  times  this 
amount.  In  weak  solutions  slowly  injected,  much  larger  amounts  can 
be  used  than  in  concentrated  solutions,  or  with  rapid  injection.  The 
brain  and  central  nervous  system  are  most  susceptible  to  cocain.  Sensory 
nerves  are  more  rapidly  affected  than  motor.  The  mildest  symptom  of 
poisoning  is  slight  dizziness,  and  from  this  there  are  all  grades  leading 
to  collapse,  convulsions,  and  death.  The  inhalation  of  amyl  nitrite  is  the 
best  antidote  for  the  early  symptoms.  In  considering  the  question  of 
toxicity  of  cocain,  I  can  truly  state  that  in  a  very  large  experience  I 
have  never  seen  any  symptoms  which  could  be  certainly  attributed  to  it, 
nor  have  I  ever  seen  a  real  instance  of  so-called  idiosyncrasy.  I  believe 
with  Bodine  that  epigastric  discomfort,  transient  pallor,  and  sweating, 
often  seen  at  the  beginning  of  an  operation,  are  purely  psychic  and  not 
toxic,  and  I  have  found  that  these  disappear  quickly  with  the  adminis- 
tration of  a  few  whiffs  of  aromatic  spirits  of  ammonia  or  lowering  of  the 
head.  I  have  used  cocain  almost  exclusively,  and,  except  when  large 
amounts  are  necessary,  I  see  no  great  advantages  in  its  less  toxic  substi- 
tutes. 

Preparation  of  Solutions. — Solutions  of  cocain  are  more  or  less  un- 
stable chemically,  and  do  not  stand  repeated  or  prolonged  boiling.  It  is 
better  to  have  freshly  prepared  solutions  in  order  to  insure  constant  and 
definite  results.  They  may  be  boiled  once  immediately  before  using 
without  injury.  In  the  preparation  of  any  solution  for  the  production  of 
local  anesthesia,  certain  facts  should  be  borne  in  mind.  Water,  forcibly 
injected  into  the  skin,  will  produce  a  transient  anesthesia  of  the  edema- 
tized  area.  It  is  accomplished  at  the  expense  of  pain,  hence  the  term 
"anesthesia  dolorosa,"  applied  by  Liebreich.  Chemically  indifferent 
fluids  of  the  same  specific  gravity  and  the  same  freezing  point  as  the 
tissue  fluids,  when  injected  slowly,  do  not  cause  pain  or  anesthesia.  Such 
fluids  are  called  isotonic.  Normal  physiologic  salt  solution  is  an  example. 
Fluids  of  greater  or  less  osmotic  tension  cause  pain  by  drawing  water 
from  the  tissues  or  by  causing  them  to  swell.  By  the  use  of  isotonic 
physiologic  salt  solution  as  a  vehicle  for  analgesic  drugs,  the  tissues  are 
not  injured  and  recover  promptly.  The  salt  solution  has  no  physical 
effect  itself,  but  allows  the  drug  to  act  alone.  Schleich  believed  that  the 
edematization  of  the  tissues  was  the  essential  factor,  and  laid  little  stress 


480  ANESTHESIA 

on  the  analgesic  drug.  This  idea  has  been  rather  disproved  in  the  de- 
velopment of  the  method,  and  more  and  more  dependence  has  been  placed 
on  the  analgesic  action  of  the  drug.  A  satisfactory  solution  should  there- 
fore be  isotonic  with  the  tissue  fluid,  and  should  be  capable  of  control  as 
to  absorption.  The  first  condition  is  attained  by  the  addition  of  sodium 
chlorid  and  the  second  by  adrenalin.  Except  in  special  work  where  appli- 
cation is  to  be  made  to  mucous  membranes,  only  two  strengths  will  be 
necessary — one  per  cent  and  one-tenth  of  one  per  cent  cocain.  The 
formulas,  as  given  by  Braun,  are: 

A      Cocain    hydrochlorid    0.1     gm. 

Physiologic  salt  solution  (0.9  per  cent) 100         c.c. 

0.1%  Adrenalin     (1:1000)      5          drops. 

B      Cocain    hydrochlorid    0 . 0.5  gm. 

Physiologic  salt  solution   (0.9  per  cent) 5.        c.c. 

1%    Adrenalin     (1:1000)     10          drops. 

The  one  per  cent  solution  is  used  for  the  direct  injection  of  nerve  trunks, 
or  for  local  application  to  mucous  membranes.  Strong  solutions  act 
much  more  quickly  than  weak  ones;  so  that,  where  immediate  action  is 
required  and  the  amount  to  be  used  is  small,  as  in  the  removal  of  warts, 
moles,  or  small  tumors,  this  solution  may  be  used  to  advantage.  In 
more  extensive  operations,  for  skin  injection  and  general  infiltration, 
the  one-tenth  of  one  per  cent  solution  is  used.  The  adrenalin  content 
not  only  controls  absorption,  but  prolongs  anesthesia,  so  that  the  skin  is 
found  blanched  and  anesthetic  at  the  end  of  two  or  three  hours.  The 
whole  amount  of  either  of  these  formulas  may  be  safely  used  in  a  single 
operation,  and  I  have  often  used  the  whole  of  both.  Although  such  an 
amount  might  be  considered  toxic,  the  adrenalin  control  may  be  relied 
upon,  and  a  great  part  of  the  injected  fluid  escapes  during  the  course  of 
the  operation,  or  is  removed  with  the  tissues  which  may  be  taken  away. 
In  operations  where  large  amounts  are  to  be  used  or  where  extensive 
edematization  is  desirable,  as  in  thyroidectomy,  solution  A  may  be 
diluted  three  or  four  times  with  salt  solution,  thus  obtaining  a  strength 
of  from  1 :  1,000  to  1 :  5,000. 

Sterilizing  the  Solutions.^ — These  solutions,  minus  the  adrenalin, 
may  be  boiled  just  before  use  and  the  adrenalin  added  drop  by  drop. 
Cocain  solutions  stand  sterilization  in  the  autoclave  very  well  (20  min- 
utes at  115° — 120°  C),  and  if  corked  immediately  afterward  will  retain 
their  activity  for  a  long  time.  A  convenient  method  of  preparation  is  to 
place  the  solution  in  small  bottles  of  one  to  four-ounce  capacity.  The 
bottle  is  fitted  with  an  ordinary  wooden  cork,  over  which  is  placed  a 
loose  hold  of  cotton  covered  with  gauze,  secured  by  a  rubber  band  around 
the  neck  of  the  bottle.  Before  placing  in  the  autoclave  the  cork  is 
^See   Chapter   XV   for   Bainbridge's   Method. 


LOCAL  ANESTHESIA 


481 


loosened,  without  lifting  the  hood,  and  as  soon  as  the  sterilization  is  com- 
pleted the  cork  is  driven  in  in  the  same  manner.  When  about  to  be  used 
the  cork  and  hood  are  removed  together,  leaving  a  sterile  surface  over 
which  to  pour  out  the  solution.  A  much  better  method,  however,  is  to 
have  the  desired  amount  of  cocain  and  adrenalin  in  tablet  form.  The 
tablet,  prepared  according  to  the  formula  of  Braun,  contains  cocain 
hydrochlorid  0.05  gni.  (•%  gr.)  and  adrenalin  0.00016  gm.  (1/400  gr.). 
Two  tablets  are  placed  in  a  small  vial  between  layers  of  cotton,  for  the 


-"^fc. 


Fig.  182. — Syringes  and  Solution  Bottles  for  Local  Anesthesia. 
A,  Set  of  glass  syringes  of  assorted  sizes;  B,  Ordinary  hypodermic  syringe-glass  with 
asbestos  packing;  C,  Larger  syringe  of  same  type;  D,  All  metal  syringe;  E,  Cannula  for 
intravenous  anesthesia;  F,  Porcelain  cups  for  holding  sterilized  solutions;  G,  Bottles  of 
sterilized  salt  solution;  H,  Vigl  containing  tablets  of  cocain  and  adrenalin. 

preparation  of  the  two  solutions.  The  vials  are  plugged  with  cotton  held 
in  place  with  a  gauze  hood,  and  are  sterilized  by  dry  heat  at  80°  C.  for 
an  hour  on  three  successive  days.  Immediately  before  operation  the 
tablets  are  dissolved  in  sterile  physiologic  salt  solution,  thus  yielding 
fresh  isotonic  solutions.  One  tablet  dissolved  in  5  c.  c.  of  salt  solution 
makes  a  strength  of  one  per  cent,  and  in  50  c.  c.  one-tenth  of  one  per 
cent.  The  adrenalin  content  in  the  weak  solution  is  about  1 :  300,000. 
The  salt  solution  is  most  conveniently  prepared  in  small  bottles  sterilized 
in  the  autoclave,  according  to  the  method  given  above  for  the  preparation 
of  cocain  solutions.  Tablets  prepared  in  this  way  have  been  kept  for 
many  months  and  both  the  cocain  and  adrenalin  have  been  found  quite 
active.    This  method  will  be  found  a  great  convenience  when  operations 


482  ANESTHESIA 

are  to  be  done  away  from  hospital  surroundings.  Bodine's  tubes  are  also 
very  convenient,  and  can  be  obtained  already  sterilized.  Each  tube  con- 
tains cocain  hydrochlorid  0.06  gm.  and  sodium  chlorid  0.18  gm.  The 
contents  of  one  tube  dissolved  in  an  ounce  of  sterile  water  will  yield  a 
solution  which  can  be  diluted  with  salt  solution  to  obtain  weaker 
strengths  for  infiltration.  The  older  solutions  of  Schleich  containing 
niorphin  in  addition  to  cocain  are  no  longer  used.  The  morphin  is  much 
better  given  as  a  hypodermic  before  operation. 

Eucain  B  has  in  its  favor  the  facts  that  its  solutions  stand  boiling 
well,  that  it  is  3.75  times  less  toxic  than  cocain,  and  that  it  is  mildly 
antiseptic.  Matas  states  that  as  much  as  8  to  10  gr,  remaining  in  the 
tissues  is  well  tolerated.  It  is  not  as  effective  as  cocain,  anesthesia  being 
produced  more  slowly  and  wearing  off  more  quickly.  For  small  opera- 
tions where  quick  anesthesia  is  desired  cocain  is  much  to  be  preferred, 
though  when  large  amounts  of  solution  are  to  be  used  eucain  may  offer 
an  advantage  through  its  lesser  toxicity.  It  is  used  in  the  same  strength 
as  cocain  and  may  be  combined  with  adrenalin. 

Novocain. — Novocain,  discovered  by  Einhorn,  was  first  clinically 
tested  by  Braun  in  1905.  It  has  been  extolled  by  him  in  several  papers,^ 
and  has  been  quite  generally  adopted.  It  is  now  recognized  as  the  best 
and  safest  substance  for  the  production  of  local  anesthesia.  It  is  from 
seven  to  ten  times  less  toxic  than  cocain.  Its  solutions  stand  boiling  and 
keep  for  a  long  time  without  deteriorating.  Its  action  is  increased  and 
prolonged  by  the  addition  of  adrenalin.  It  is  conveniently  supplied  in 
tablet  form.  The  ordinary  strength  for  infiltration  purposes  is  0.5  per 
cent,  and  for  the  injection  of  nerve  trunks  or  for  rapid  results  in  a  small 
field  1,  2,  or  4  per  cent.  Braun  states  that  as  much  as  250  c.  c.  of  a  0.5 
per  cent  solution,  or  135  c.  c.  of  a  1  per  cent  solution,  can  be  injected 
without  fear  of  intoxication,  but  cautions  that  in  spite  of  this  we  should 
ever  bear  in  mind  that  novocain  is  a  poison.  In  the  preparation  of  solu- 
tions the  same  general  principles  apply  as  have  been  described  for  those 
of  cocain.  They  should  be  isotonic,  fresh,  and  absolutely  sterile.  For 
ordinary  purposes  a  4  per  cent  stock  solution  of  novocain  in  distilled 
water  may  be  sterilized,  sealed,  and  kept  on  hand.  This  is  diluted  just 
before  using  with  sterile  normal  salt  solution  and  adrenalin  added  in 
the  proportion  of  0.001  gm.  to  25  c.  <i.  of  the  stock  solution.  The  most 
convenient  method  is  to  make  up  fresh  solutions  from  novoeain-supra- 
renin  tablets.  The  best  of  these  prepared  according  to  Braun's  directions 
contains  novocain  hydrochlorid  (0.125  gm.)  and  synthetic  suprarenin 
(0.000125  gm.).  These  tablets  are  supposed  to  be  sterile;  but  it  is  safer 
to  insure  sterilization  by  boiling,  which  does  not  destroy  the  activity  of 
the  synthetic  suprarenin.    One  tablet  dissolved  in  25  c.  c.  of  normal  salt 

^  Braun:      JDeutsch.   med.    Woch.,   1905,   31,    1667;    Deutsche  Ztschr.  f.   Chir., 
1911,  3,  321;  LoTcalancesthesie,  Ed.  3,  1913. 


LOCAL  ANESTHESIA  483 

solution  gives  a  0.5  per  cent  solution,  and  two  tablets  in  the  same  amount 
a  1  per  cent  solution.  The  tablets  for  the  required  amount  of  solution 
are  best  dissolved  in  a  small  amount  of  normal  salt  solution  and  boiled  in 
a  porcelain  dish  over  a  flame,  and  then  the  necessary  amount  of  normal 
salt  solution  is  added.  It  should  be  borne  in  Uiind  that  one  can  use 
with  safety  a  much  larger  amount  of  novocain  injected  slowly  in  weak 
solution  than  in  a  strong  solution  rapidly  injected,  for  the  same  reasons 
as  have  been  stated  for  cocain.  Jfovocain  is  somewhat  slower  than  cocain 
in  its  action,  and  it  is  therefore  wise  to  wait  a  few  minutes  after  inject- 
ing it  before  beginning  an  operation. 

TTrea  and  Quinin  Hydrochlorid. — This  was  suggested  in  1907  by 
Thibault  as  a  substitute  for  cocain.  It  can  be  obtained  as  powdered 
crystals  in  tablet  form  or  in  solution  in  sealed  tubes.  It  is  claimed  for 
it  that  after  its  injection  anesthesia  appears  quickly  and  lasts  for  several 
hours  or  days,  thus  eliminating  post-operative  pain;  that  its  toxicity  is 
practically  nothing;  and  that  it  causes  a  deposition  of  fibrin  which 
serves  to  prevent  post-operative  hemorrhage.  It  has  therefore  been  espe- 
cially recommended  in  the  removal  of  tonsils  and  in  operations  about 
the  anus  and  rectum,  and  as  an  injection  in  operations  under  local  or 
general  anesthesia  for  the  prevention  of  post-operative  pain.  For  appli- 
cation to  mucous  membranes  10  to  20  per  cent  solutions  are  used,  while 
for  injection  purposes  the  ordinary  strength  is  0.5  to  1  per  cent.  Where 
prolonged  action  is  desired  it  is  advised  to  wait  from  5  to  30  minutes 
or  longer  before  beginning  the  operation.  This  anesthetic  has  been  tried 
by  many  surgeons,  and  seems  to  have  gained  in  favor.  It  has,  moreover, 
some  strong  advocates,  notably  Hertzler.^ 

Numerous  other  drugs  have  for  one  reason  or  another  been  exploited ; 
but,  with  the  exception  of  novocain,  none  is  very  popular  at  the  present 
.time.  It  would  seem  that  with  cocain,  novocain,  and  quinin  all  the  re- 
quirements of  local  anesthesia  of  to-day  can  be  fulfilled. 

Syringes.— Syringes  for  injection  purposes  may  be  of  any  type  which 
can  be  boiled.  For  ordinary  work  the  usual  hypodermic  syringes  are 
satisfactory,  and  for  minor  operations  the  all-metal  one  has  proved  most 
economical,  and  will  last  for  years  without  need  of  repair.  In  more  ex- 
tensive operations  and  for  the  intravenous  method  larger  glass 
syringes  are  suitable.  Sets  of  them  can  be  obtained  with  needles  of 
assorted  sizes;  the  syringe  barrels  being  graduated  in  order  to  note  the 
amount  of  anesthetic  used.  The  syringes  should  be  boiled  in  plain  water, 
and  after  operation  should  be  carefully  dried  and  a  drop  of  castor  oil 
run  into  them.  This  keeps  the  packing  from  drying  out,  and  in  the  case 
of  all-metal  or  all-glass  syringes  prevents  sticking  of  the  piston.  Steel 
needles  are  quite  satisfactory,  and  a  variety  of  sizes  should  be  kept  on 

^Hertzler:  J.  Am.  Med.  Assn.,  1909,  53,  1393;  also  "Surgical  Operations 
with  Local  Anesthesia,"  1912. 


484  ANESTHESIA 

hand,  varying  from  the  short  hypodermic  needles  to  those  8  or  10  cm. 
in  length,  for  deep  injections.  These  should  be  thoroughly  dried  after 
use  and  a  wire  inserted  in  each  to  preserve  the  patency  of  its  lumen. 
Needles  of  platinum  or  nickel  possess  the  very  distinct  advantage  of  free- 
dom from  occlusion  by  rust,  and  though  expensive  are  probably  more 
economical  because  of  their  longer  life.  There  is  no  necessity  of  a  syringe 
larger  than  one  of  20  c.  c.  capacity.  In  the  days  when  Schleich's  method 
prevailed  and  edematization  of  tissues  rather  than  drug  action  was  de- 
pended upon  there  was  more  need  of  such  an  apparatus  as  that  of  Matas. 
This  consists  of  a  graduated  bottle  containing  the  anesthetizing  fluid 
under  compressed  air.  The  tube  to  which  the  injecting  needle  is  at- 
tached is  controlled  by  a  stopcock,  and  the  fluid  can  be  forced  into  the 
tissues  in  any  amount  and  under  any  desired  pressure.  Where  several 
cases  are  to  be  done  in  succession,  it  would  save  time  and  avoid  the 
necessity  of  repeated  punctures. 

Indications  and  Scope  of  Local  Anesthesia. — The  last  few  years  have 
shown  a  steadily  increasing  interest  in  the  whole  subject  of  anesthesia. 
JSTew  methods  of  administering  general  anesthetics  have  been  developed 
and  the  dangers  of  general  anesthesia  lessened.  The  administration  of 
anesthetics  has  been  taken  from  the  hands  of  the  green  interne  in  hos- 
pitals, and  specialists  in  this  particular  branch  have  developed.  Condi- 
tions have  greatly  improved  in  this  respect.  Nevertheless  there  still 
remains  a  large  field  of  usefulness  for  local  anesthesia,  and  in  many  in- 
stances an  absolute  necessity  exists.  America,  the  birthplace  of  local 
anesthesia,  has  left  its  development  to  European  surgeons,  and  only 
lately  has  shown  a  revival  of  interest.  One  still  sees  a  great  deal  of 
skepticism  and  distrust,  which  can  mostly  be  attributed  to  ignorance  of 
the  technique  and  its  possibilities.  I  have  seen  men  attempting  opera- 
tions under  local  anesthesia  who  showed  from  the  first  needle  prick  their 
absolute  unfamiliarity  with  its  general  principles,  and  have  heard  them 
later  express  their  opinions  as  to  the  unsatisfactoriness  of  the  method. 
American  hurry,  too,  is  in  a  large  part  responsible.  In  spite  of  skill, 
these  operations  usually  require  more  time.  From  the  patient's  stand- 
point, the  question  is  different.  One  rarely  hears  a  patient  who  has  been 
through  an  operation  in  skilled  hands  condemn  the  method  or  select  a 
general  anesthetic  for  a  second  experience.  In  our  clinic  there  is  a 
distinctly  growing  class  of  patients  who  demand  a  local  anesthetic.  This 
applies  especially  to  hernia  cases,  where  a  general  anesthetic  is  never 
given.  Again,  there  are  those  patients  of  greatly  lowered  vitality,  in 
whom  general  anesthesia  of  itself  might  be  enough  to  turn  the  scale 
downward,  who  may  be  safely  carried  through  a  serious .  surgical  pro- 
cedure under  local  anesthesia.  Haste  is  unnecessary ;  operations  may  be 
much  more  thoroughly  and  carefully  done  than  where  every  effort  is 
bent  on  shortening  the  period  of  anesthesia.     Thus  in  strangulated  her- 


LOCAL  ANESTHESIA  485 

nias,  especially  where  the  strangulation  has  lasted  some  time,  I  believe 
local  anesthesia  imperative,  an  opinion  shared  by  Lund  ^  and  Bodine.^ 
An  important  and  large  class  includes  a  host  of  minor  procedures  often 
considered  too  trivial  for  general  anesthesia  and  usually  done  with- 
out any  anesthetic — exploratory  punctures,  opening  of  furuncles,  etc. 
These  can  be  treated  more  thoroughly  and  with  vastly  more  comfort  to 
the  patient  with  the  aid  of  a  little  cocain.  Many  persons  who  would 
rather  bear  such  ills  as  disfiguring  scars,  benign  tumors,  small  anal 
fissures  or  hemorrhoids  than  submit  to  a  general  anesthetic  will  gladly 
welcome  their  removal  under  local  anesthesia.  When  hospital  con- 
veniences are  wanting  or  assistants  not  at  hand,  as  in  country  practice, 
a  knowledge  of  the  principles  of  the  various  local  methods  will  make  the 
apparently  impossible  an  easy  possibility.  A  recent  report  from  an  Aus- 
tralian physician,^  located  115  miles  from  the  nearest  medical  man, 
gives  an  account  of  such  extensive  work  as  hernia  operations,  external 
urethrotomy,  and  complete  excision  of  the  glands  of  the  groin  repeat- 
edly and  successfully  accomplished  under  local  anesthesia  with  cocain 
and  adrenalin. 

Local  versus  General  Anesthesia. — Where  general  narcosis  is  abso- 
lutely contraindicated,  as  by  extensive  pulmonary  involvement,  many 
operations  may  be  performed  by  local  means  without  any  change  in  the 
patient's  general  condition.  In  many  instances  where  there  are  no  con- 
traindications whatever  to  a  general  anesthetic,  the  comfort  of  the  pa- 
tient after  operation,  the  absence  of  nausea  and  vomiting,  and  the  addi- 
tional element  of  safety  are  enough  to  decide  in  favor  of  the  local  pro- 
cedure. There  is  no  doubt  that  the  blocking  of  the  transmission  of  nerve 
impulses  from  the  field  of  operation  is  a  valuable  factor  in  the  prevention 
of  shock.  This  has  been  thoroughly  demonstrated  by  Kocher  and  Crile, 
who  in  bad  operative  risks,  _when  operating  under  general  anesthesia,  at 
the  same  time  shut  off  the  field  of  operation  from  the  brain  by  a  thor- 
ough infiltration  with  cocain  or  novocain.  Crile  *  states  that,  "if  one 
combines  a  complete  local  anesthesia  with  a  general  anesthesia  and  avoids 
fear,  then  it  matters  not  how  poor  the  risk,  nor  how  extensive  the  opera- 
tion, the  nervous  system  is  wholly  protected  and  the  immediate  opera- 
tive risk  wholly  eliminated."  There  is  no  absolute  rule;  but  it  is  safe 
to  say  that,  when  the  field  of  operation  can  be  made  painless  and  the 
operative  procedure  as  well  carried  out  under  local  anesthesia  as  with 
general  narcosis,  local  anesthesia  may  be  the  method  of  choice.  The 
question  of  time  may  figure  largely  in  this  choice,  and  one  of  the  greatest 
factors  against  the  local  method  is  the  amount  of  time  consumed  and 

*Lund:     Ann.  of  Surg.,  1911,  54,  420. 
"  Bodine :     Ann.  of  Surg.,  1907,  45,  871. 
^Triado:     Australian  Med.  Gaz.,  1911,  30,  359. 
*  Crile:     Surg.,  Gyn.  and  Obstet.,  1911,  13,   170. 


486  ANESTHESIA 

the  greater  strain  on  the  surgeon  himself.  In  children  and  very  nerv- 
ous individuals  it  is  often  unsatisfactory.  I  believe,  though,  that  the 
very  nervous  individual  is  rare  who  cannot  be  brought  to  a  neutral  state 
by  establishing  a  condition  of  mutual  confidence  which  should  exist  be- 
tween surgeon  and  patient,  and  by  a  preliminary  dose  of  morphin.  I 
have  been  able  to  circumcise  a  boy  of  five  and  operate  for  hernia  on  an- 
other of  ten  years  with  local  anesthesia. 

Mortality. — N^euber  ^  in  1909  collected  the  statistics  of  112  surgeons 
in  Germany,  and  stated  that  local  anesthesia  or  the  first  whiffs  of  ether 
were  utilized  in  fully  a  quarter  of  all  cases  that  would  have  required 
general  anesthesia  twenty  years  ago,  and  that  no  fatality  was  reported. 
Certainly  the  danger  of  post-operative  pulmonary  and  renal  disturbances 
is  greatly  lessened — a  most  desirable  fact  in  the  aged. 

General  Preparation  and  Technique. — The  general  preparation  of  the 
patient  is  the  same  as  for  general  narcosis ;  except  that,  unless  especially 
contraindicated  by  the  nature  of  the  operation,  a  cup  of  coffee  or  a  very 
light  breakfast  may  be  taken.  It  is  really  better  when  possible  to  have 
something  in  the  stomach.  An  hour  before  operation  a  hypodermic 
injection  of  morphin  sulphate  (gr.  1/6)  is  given,  and  to  this  may  be 
added  a  small  dose  of  scopolamin  (gr.  1/200-1/150).  Crile  ^  says  that 
"imder  the  influence  of  morphin  and  scopolamin  no  one  is  a  coward,  no 
one  is  brave,  everyone  is  in  a  neutral  state."  The  patient  should  be  re- 
assured as  to  the  nature  of  the  operation  and  its  probable  outcome,  and 
the  surgeon  should  have  the  confidence  of  the  patient.  When  brought 
into  the  operating  room,  instruments  and  preparations  should  as  far  as 
possible  be  kept  out  of  sight,  and  a  quiet  though  cheerful  atmosphere 
should  prevail.  The  recumbent  position  is  the  unbroken  rule  even  for 
the  most  trivial  procedure.  The  table  should  be  made  comfortable  by 
means  of  a  rubber-covered  soft  mattress  and  a  pad  to  support  the  spine. 
Too  much  stress  cannot  be  laid  on  the  importance  of  this  pad  under  the 
spine,  whether  the  anesthesia  be  general  or  local.  There  is  no  doubt 
that  nearly  all  the  backache  following  operations  can  be  avoided  by  atten- 
tion to  this  slight  detail. 

Details  as  to  Comfort  of  Patient. — Sensibility  to  pain  undoubtedly 
differs  in  individuals,  and  varies  with  race,  age,  culture,  intelligence,  and 
mental  condition.  The  importance  of  psychic  pain  should  not  be  under- 
estimated, and  the  "moral  anesthetist"  is  a  most  useful  factor.  His 
duty  is  to  record  the  pulse  and  to  talk  with  the  patient,  to  divert  his 
attention  from  the  operation  or  to  encourage  him  as  to  its  progress. 
An  occasional  sip  of  water,  a  whiff  of  aromatic  ammonia,  or  a  reassuring 
remark  may  tide  over  an  important  step  in  the  operation  or  may  ward 
off  impending  nausea  and  other  psychic  phenomena.     I  frequently  allow 

'Neuber:     ArcMv  f.  Min.  Chir.,  1909,  89,  IIU. 
^Crile:     Surg.,  Gynec.  and  Obstet.,  1911,  13,  170. 


LOCAL  ANESTHESIA 


487 


patients  to  smoke,  and  often  the  anticipation  of  a  promised  drink  of 
whiskey  will  keep  their  thoughts  far  from  the  field  of  operation.  On  the 
part  of  the  surgeon  himself,  there  are  certain  essentials  to  success,  first 
of  which  is  plenty  of  time.  He  should  be  able  to  converse  without  inter- 
fering with  his  work,  an  accomplishment  readily  attained  with  practice. 
He  must  often  change  his  whole  style  of  operating,  avoiding  the  desire 
for  rapid  and  brilliant  work  and  cultivating  tact,  patience,  self-control, 


Fig. 


183. — Showing  Triangular  Pad  Supporting  Back  and  Sandbag  as  Support 

FOR  Feet. 


and  attention  to  details.  Care  must  be  taken  in  sponging  and  in  the 
placing  of  retractors  and  their  handling  by  assistants.  Haste  is  always 
to  be  avoided,  and  gentle  handling  of  the  tissues  is  imperative.  The 
accidental  clamping  of  a  nerve  trunk  or  traction  on  some  sensitive  area 
in  the  early  stages  of  an  operation  is  apt  to  shake  the  patient's  confi- 
dence and  interfere  materially  with  success.  There  is  demanded  then 
of  the  surgeon  not  only  familiarity  with  the  course  and  distribution  of 
sensory  nerve  trunks,  but  an  accurate  knowledge  of  the  sensibility  of  the 


488  ANESTHESIA 

various  tissues  and  organs  to  pain.  Much  of  our  knowledge  in  this  re- 
spect we  owe  to  the  painstaking  observations  of  Lennander.^  The  skin 
is  everywhere  sensitive,  but  varies  somewhat  in  different  locations.  Once 
through,  the  skin,  fat,  muscle,  tendon,  and  fascia  are  insensitive,  if  nerve 
trunks  and  large  vessels  are  avoided;  likewise  bone  and  cartilage,  while 
periosteum  and  synovial  membranes  are  exquisitely  sensitive.  Abdominal 
organs  are  not  sensitive  to  pain,  but  the  parietal  peritoneum,  on  the 
other  hand,  is  acutely  so.  Bearing  these  facts  in  mind,  having  proper 
solutions  and  instruments,  the  surgeon  will  find  little  difficulty  in  accom- 
plishing extensive  operative  procedures  under  local  anesthesia,  and  his 
success  will  increase  steadily  with  experience. 

After-treatment. — The  after-treatment  does  not  differ  greatly  from 
that  after  general  narcosis,  except  that  liquid  nourishment  may  be  begun 
immediately,  as  nausea  does  not  interfere.  After  abdominal  operations 
it  is  better  during  the  first  twenty-four  hours  to  limit  the  diet  to  liquids 
to  prevent  distention. 

Healing. — Healing  is  in  no  way  hindered.  I  have  never  seen  slough- 
ing from  the  anesthetic  except  once,  when  a  nurse  made  up  the  cocain 
solution  with  saturated  instead  of  normal  physiologic  salt  solution.  A 
similar  experience  is  reported  by  Strobe.^  If  anything,  healing  is  bet- 
ter as  a  rule  than  with  general  anesthesia,  a  fact  which  can  be  attributed 
to  the  gentler  handling  of  tissues  enforced  by  the  use  of  local  methods. 

Combination  of  Local  and  General  Anesthesia. — While  any  one  of 
the  methods  about  to  be  described  may  suffice  for  the  successful  anes- 
thetization of  the  operative  field  in  individual  cases,  it  often  hap- 
pens that  it  is  necessary  to  use  a  combination  of  methods.  It  should  be 
remembered  also  that  there  are  useful  combinations  of  local  and  general 
anesthesia.  An  operation  may  be  started  under  local  anesthesia,  and 
when  a  procedure  is  reached  which  must  of  necessity  be  painful  some 
general  anesthetic  is  administered.  Under  such  conditions  a  few  whiffs 
will  often  suffice  to  tide  over  the  painful  step,  or  if  it  be  desired  to  obtain 
narcosis  this  can  be  done  with  less  anesthetic  than  would  be  required 
ordinarily. 

METHODS 

The  methods  practiced  in  local  anesthesia  Avill  be  considered  under 
the  following  heads:  (1)  surface  anesthesia;  (2)  infiltration;  (3)  the 
regional  method;  (4)  venous  anesthesia;  (5)  arterial  anesthesia. 

Surface  Application. — Cocain,  or  other  analgesic  drug,  applied  to 

'Lennander:  CentraXbl.  f.  Chir.,  1901,  8;  Mitt.  a.  d.  Grensgeb.  d.  Med.  u. 
CMr.,  1902,  10,  38;  1906,  15,  465;  16,  19;  16,  24;  also  "Tr.  Sect,  on  Surg.," 
Am.  Med.  Ass7i.,  1907,  211. 

^Strobe:     Deut.  Ztsch.  f.  Chir.,  1909,  99,  201. 


LOCAL  ANESTHESIA  489 

mucous  membranes  by  means  of  the  spray  or  swab  will  produce  loss  of 
sensibility.  Its  use  in  this  way  is  confined  for  the  most  part  to  special 
work,  as  laryngology  or  ophthalmology.  Very  strong  solutions  were  for- 
merly used  (10  per  cent  cocain),  but  the  tendency  now  is  to  reduce  the 
strength.  As  a  matter  of  fact,  0.5  per  cent  to  1  per  cent  is  quite  sufficient. 
With  these  weaker  solutions  anesthesia  appears  more  slowly,  but  in  time 
is  just  as  thorough.  Here,  as  elsewhere  in  local  work,  one  must  not 
hurry,  but  should  wait  for  10  to  30  minutes  before  beginning  any  step 
likely  to  cause  pain.  Cocain  may  be  applied  in  this  way  to  produce  far- 
reaching  effects,  as  when  anesthesia  of  the  teeth  is  brought  about  by 
the  placing  of  a  cocain  tampon  in  the  nose. 

Infiltration. — By  this  we  mean  an  artificial  edema  produced  by  in- 
jecting fluid  into  the  tissues.  Anesthesia  may  be  thus  brought  about 
physically  with  plain  water  or  salt  solution.  The  older  method  of 
Schleich  ^  depended  upon  the  pressure  rather  than  the  drug  action  for  its 
effect,  an  error  which  was  corrected  by  the  later  work  of  Eeclus  ^  and 
others,  in  which  the  tissues  are  injected  layer  by  layer  as  encountered. 
Braun  ^  accomplishes  the  same  thing  by  a  circumscribing  injection 
through  one  or  more  punctures,  and  aims  to  anesthetize  the  nerves  be- 
fore they  reach  the  skin  or  the  field  of  operation,  thus  making  it  unneces- 
sary to  separately  anesthetize  the  skin.  This  naturally  requires  waiting 
for  from  15  to  30  minutes  before  beginning  the  operation.  In  my  ex- 
perience, it  is  much  more  satisfactory  to  produce  a  skin  wheal  in  all 
cases  so  that  the  operation  may  be  started  almost  immediately  after  the 
injection,  and  while  the  skin  is  being  reflected  the  deeper  injection  is 
taking  effect.  Bier  *  regards  Braun's  method  as  the  preferred  technique 
of  to-day  and  novocain  (0.5  pet  cent  -|-  adrenalin)  as  the  best  drug.  He 
adds  that  the  secret  of  success  in  extensive  operations  lies  not  only  in 
using  the  anesthetizing  solution  freely,  bu.t  in  waiting  long  enough  for 
it  to  take  effect,  i.  e.,  the  operation  should  not  be  started  for  at  least 
15  minutes  after  the  injection.  For  a  circumscribed  tumor,  for  instance, 
this  method  is  ideal.  The  line  of  incision  is  marked  by  one  or  more 
skin  wheals,  and  through  them  the  whole  region  about  the  tumor  is  freely 
injected.  Then,  after  waiting  a  sufficient  time,  the  extirpation  can  be 
painlessly  done.  In  many  instances,  though,  the  procedure  of  Eeclus — 
injecting  layer  by  layer  as  the  tissues  are  encountered — will  be  satisfac- 
tory. Here  the  sensitive  tissues  only  are  injected,  and  special  attention 
is  paid  to  blood  vessels  and  regions  likely  to  carry  sensory  nerves.  Weak 
solutions  (0.1  per  cent  cocain  or  0.5  per  cent  novocain)  are  used  for 
all  such  infiltrations. 

^  Schleich :     ' '  Schmerzlose  Operationen, ' '  Berlin,  1894. 
^Eeclus:      " L 'Anesthesie  localisee,  etc.,"  Paris,   1903. 
^  Braun:     *  *  Lokalanaesthesie, "  Leipzig,  1913. 
*Bier:     Archiv  f.  Uin.  CMr.,  1909,  90,  349. 


490  ANESTHESIA 

The  Regional  Method. — This  aims  to  reach  the  nerves  which  supply 
the  field  of  operation,  often  at  a  distance.  The  anesthetizing  fluid  is  dis- 
tributed about  a  nerve  trunk  so  that  it  is  bathed  in  it  (perineural)  or 
is  injected  directly  into  its  substance  (endoneural).  This  method  was 
first  demonstrated  by  Halsted  ^  on  the  inferior  dental  nerve  for  the 
painless  extraction  of  teeth.  It  is  capable  of  very  wide  application,  and 
has  been  extensively  employed  by  Braun,  Crile,^  Matas,^  Gushing^*  and 
others,  who  by  its  use  have  been  able  to  perform  such  extensive  opera- 
tions as  shoulder  amputation  or  excision  of  the  upper  jaw.  In  peri- 
neural injection  the  time  required  to  produce  anesthesia,  and  the  thor- 
oughness of  the  anesthesia,  naturally  depend  upon  the  size  of  the  nerve 
trunk  and  the  strength  of  the  solution.  Strong  solutions  (0.5  to  1  per 
cent  cocain)  are  used  about  larger  trunks,  as  the  ulnar  at  the  elbow. 
In  blocking  off  a  large  number  of  smaller  fibers,  as  the  ascending 
branches  in  the  scalp  or  the  radial  nerve  about  the  wrist,  the  ordinary 
infiltration  solution  will  suffice  (0.1  per  cent  cocain  or  0.5  per  cent  novo- 
cain). In  endoneural  injection  the  needle  is  thrust  directly  into  the 
nerve  and  the  fluid  injected  until  the  nerve  appears  edematous  and 
swollen.  The  needle  should  point  centrally,  as  this  prevents  traction 
and  causes  less  pain.  There  is  ordinarily  no  complaint  of  pain  when  the 
needle  is  introduced.  The  conductivity  of  the  nerve  to  all  impulses  is 
immediately  blocked.  Usually  the  nerve  must  first  be  exposed  by  dissec- 
tion, but  occasionally  a  superficial  nerve,  as  the  ulnar,  may  be  reached 
through  the  skin.  Here  also  the  strong  solutions  (0.5  to  1  per  cent  co- 
cain) give  the  most  rapid  anesthesia.  Endoneural  and  perineural  in- 
jection have  had  their  greatest  field  of  application  in  the  surgery  of  the 
extremities  for  resections,  amputations,  etc.  It  seems  that  they  may 
here  in  large  part  be  superseded  by  the  intravenous  or  intra-arterial 
methods.  One  of  the  most  useful  applications  is  in  the  operation  for 
hernia,  as  first  described  by  Gushing. 

Venous  Anesthesia. — In  April,  1908,  Bier  ^  presented  this  new 
method  of  local  anesthesia  for  the  limbs  by  injecting  novocain  into  the 
superficial  veins.  It  is  applicable  to  all  operations  on  the  extremities, 
such  as  tendon  transplantations,  joint  resections,  or  amputations.  It  is 
contraindicated  in  cases  of  diabetic  or  senile  gangrene.  The  most  im- 
portant point  is  the  production  of  complete  ischemia  by  means  of  rubber 
bandages.  The  limb  is  elevated,  and  a  thin  rubber  bandage  tightly  ap- 
plied from  the  fingers  or  toes  up  to  a  point  a  short  distance  above  which 
the  vein  is  exposed.    Immediately  above  this  a  second  Esmarch  bandage 

^Halsted:     N.  Y.  Med.  J.,  Dee.  6,  1884. 

^Grile:     J.  Am.  Med.  Assn.,  1902,  38,  No.  8. 

^Matas:  Trans.  Louisiana  State  Med.  Soc,  1900,  329;  see  also,  Phil.  Med.  J., 
1900,   6. 

*  Gushing:      Johns  EopTcins  Hosp.  Bull.,  1900. 

^  Bier :     Archiv  f.  Jclin.  Chir.,  1908,  86,  1007. 


LOCAL  ANESTHESIA 


491 


is  applied  as  tightly  as  possible,  being  sure  to  cover  a  broad  surface,  as  a 
narrow  bandage  soon  becomes  painful.  Beginning  centrally,  the  first 
bandage  is  removed  to  a  point  distal  to  the  field  of 
operation,  where  a  third  bandage  is  tightly  placed. 
The  field  of  operation  is  then  shut  off  on  either  side 
from  the  circulation.  The  space  between  the  two 
bandages  should  not  be  less  than  10  cm.  nor  more 
than  25  cm.  In  the  case  of  peripheral  operations  a 
single  central  bandage  only  is  applied,  but  this  should 
not  be  placed  higher  than  the  middle  of  the  forearm 
or  lower  leg,  except  for  amputations.  The  next  step 
is  to  fill  the  segment  between  the  two  bandages  with 
novocain  solution,  bringing  all  the  nerve  terminals  in 
contact  with  this  solution  by  means  of  a  reversed 
venous  supply,  thus  producing  a  direct  anesthesia  of 
the  parts  lying  deeper  and  beyond  the  distal  bandage. 
A  large  superficial  vein  should  be  selected,  and  may 
be  conveniently  marked  out  before  applying  the  ban- 
dages— the  internal  saphenous  in  the  leg  or  the  bas- 
ilic or  cephalic  in  the  arm.  A  small  transverse  in- 
cision is  made  under  infiltration  with  cocain  or  novo- 
cain, and  the  vein  dissected  free  and  ligated  as  high 
as  possible.  Using  this  ligature  as  a  retractor,  the 
vein  is  lifted  up  and  an  oblique  incision  made  into  it  with  scissors.  An 
ordinary  cannula  is  introduced,  pointing  peripherally  into  its  lumen,  and 


Fig.  184. — Method 
OF  Applying  Rub- 
BER  Bandages 
FOR  Bier's  Ven- 
ous Anesthesia. 
(Progressive  Med- 
icine, Dec,  1909.) 


Fig.  185. — Syringe  and  Cannula  for  Bier's  Venous  Anesthesia. 


tied  tightly  in  place.     The  novocain  is  slowly  injected  through  the  can- 
nula, sometimes  under  considerable  force.     The  cannula  may  be  con- 


492  ANESTHESIA 

nected  to  the  syringe  by  a  piece  of  heavy  rubber  tubing ;  but  it  is  easier, 
as  a  rule,  to  fit  the  syringe  directly  to  the  cannula.  The  superficial  veins 
between  the  bandages  fill  out  and  later  collapse,  showing  that  the  fluid 
has  passed  on.  Sometimes  a  valve  offers  opposition,  but  readily  yields  to 
the  pressure  of  the  syringe.  As  much  as  40  to  50  c.  c.  of  0.5  per  cent 
novocain  without  adrenalin  may  be  used  in  the  arm  and  70  to  80  or  100 
c.  c.  in  the  leg.  The  fluid  is  prevented  from  escaping  by  clamping  the 
connecting  tube  or  the  vein  itself.  In  small  limbs  the  segment  between 
the  bandages  is  almost  immediately  completely  anesthetized — direct 
anesthesia;  in  larger  ones  the  operation  should  not  be  started  for  a  few 
minutes.  In  from  5  to  10  minutes  there  is  complete  sensory  and  motor 
paralysis  of  the  limb  peripheral  to  the  distal  bandage — indirect  anes- 
thesia. Sensory  paralysis  appears  a  minute  or  so  earlier  than  motor. 
The  muscles  are  flaccid  and  relaxed.  The  anesthesia  persists  as  long  as 
the  proximal  Esmarch  bandage  is  left  in  place,  and  disappears  soon  after 
its  removal.  It  is  necessary  therefore  to  complete  the  operation  before 
removing  this  bandage.  The  bandage  in  time  becomes  painful.  Bier's 
longest  operation  was  one  and  three-quarter  hours.  The  bandage  being 
removed,  the  cannula  is  taken  out,  the  vein  ligated,  and  the  wound 
closed.  It  is  unnecessary  to  attempt  to  wash  out  the  novocain;  for  it 
enters  into  combination  with  the  tissues,  and  is  returned  to  the  circula- 
tion in  an  altered  form.  No  cases  of  poisoning  have  been  reported.  Ad- 
renalin is,  according  to  Bier,  not  only  unnecessary,  but  may  interfere 
with  the  distribution  of  the  anesthetic.  Intravenous  anesthesia  has  now 
been  given  a  fairly  extensive  trial,  and  has  proven  most  satisfactory  for 
all  operations  on  the  extremities.  In  traumatic  surgery  it  should  find  a 
most  useful  field.  Hay  ward  ^  reports  from  Bier,  375  operations  includ- 
ing amputations  and  fixation  of  fractures.  Anesthesia  was  complete  in 
93  per  cent.  Kaerger  ^  from  the  same  clinic  reports  another  group  of 
150  cases,  and  describes  the  application  of  this  method  to  minor  opera- 
tions on  the  hands  and  feet,  a  most  useful  procedure  in  office  or  dis- 
pensary work. 

Arterial  Anesthesia. — Goyanes  ^  in  1908  first  obtained  anesthesia  of 
a  limb  by  the  injection  of  an  anesthetic  into  an  artery.  He  later  reported 
a  series  of  operations.  The  technique  is  quite  similar  to  that  of  venous 
anesthesia,  except  that,  instead  of  a  superficial  vein,  an  important  artery 
is  exposed  between  the  two  bandages.  The  artery  is  not  opened,  but 
through  a  very  fine  needle  thrust  into  its  lumen  one  injects  50  to  100  c.  c, 
of  a  0.5  per  cent  novocain  solution.  Anesthesia  is  complete  in  from  5  to 
15  minutes,  and  lasts  as  long  as  the  proximal  bandage  is  in  place,  with 
partial  anesthesia  continuing  several  hours,  thus  minimizing  post-opera- 

^Hayward:  Arch.  f.  Jclin.  Chir.,  1912,  99,  993. 
=■  Kaerger:  Arch.  f.  Uin.  Chir.,  1912,  99,  983. 
*  Goyanes:     Centralbl.  f.  Chir.,  1909,  36,  791;  Eev.  din.  de  Madrid,  1909,  1,  12. 


LOCAL  ANESTHESIA  493 

tive  pain.  The  novocain  enters  into  combination  with  the  tissues,  and  is 
not  returned  into  the  general  circulation  as  such.  As  has  been  shown 
experimentally  by  Oppel/  the  toxic  dose  of  cocain  is  much  larger  intra- 
arterially  than  intravenously,  so  this  method  should  really  be  safer  than 
the  intravenous.  There  is  no  apparent  effect  on  the  wall  of  the  artery 
itself.  Eansohoff  ^  has  reported  a  somewhat  similar  method,  injecting  1 
c.  c.  of  2  per  cent  cocain  into  an  artery  without  exsanguinating  the  limb. 
This  technique  would  not  seem  as  satisfactory  as  the  injecting  of  a  larger 
amount  of  a  weaker  solution  into  an  empty  vessel.  The  intra-arterial 
method  seems  to  show  no  advantages  over  the  intravenous,  and  has  the 
disadvantage  that  arteries  are  more  difficult  of  access  than  superficial 
veins. 

SPECIAL  APPLICATION 

As  to  the  application  of  one  or  the  other  of  these  various  procedures 
to  individual  operations  the  discretion  of  the  operator  must  decide.  In 
certain  instances  experience  has  shown  the  fitness  of  some  particular 
method,  as  in  Cushing's  operation  for  inguinal  hernia;  in  others,  where 
there  is  no  particular  choice,  suggestions  only  can  be  given.  The  first 
thought  should  be  given  to  the  nerve  supply  of  the  field  of  operation  and 
how  it  can  best  be  reached  by  the  anesthetizing  solution.  To  give  the  de- 
tails of  the  technique  in  each  individual  operative  procedure  would  re- 
quire space  far  beyond  the  scope  of  this  work.  For  the  minute  working 
details  of  special  operations  references  will  be  given  from  time  to  time, 
while  for  the  more  extensive  applications  one  may  consult  the  works  of 
Crile,  Matas,  Schleich,  Bier,  Braun,  and  others. 

Skin. — As  has  been  stated  in  a  previous  section,  the  skin  may  be 
anesthetized  for  small  incisions  by  freezing,  by  pressure,  or  by  infiltra- 
tion. By  far  the  most  satisfactory  method  is  the  production  of  a  wheal 
by  the  injection  of  any  of  the  weak  solutions  which  have  been  discussed. 
The  line  of  incision  should  be  accurately  determined  and  the  injection 
begun  at  one  end.  The  skin  is  picked  up  between  the  thumb  and  finger 
and  firmly  compressed.  The  needle  is  then  quickly  thrust  in  obliquely 
just  beneath  the  surface,  and  the  fluid  slowly  injected  until  the  skin  turns 
white.  The  needle  is  then  pushed  along,  injecting  as  it  goes,  until  a 
wheal  has  been  raised  the  full  length  of  the  needle.  The  needle  is  with- 
drawn and  reinserted  within  the  forward  edge  of  the  wheal,  and  this 
procedure  repeated  until  the  whole  line  of  incision  is  marked  by  a  con- 
tinuous wheal.  In  this  way  the  first  needle  prick  is  the  only  painful  one. 
This  line  is  immediately  anesthetized,  and  the  incision  may  be  made  at 
once.     Careful  anesthetization  of  the  skin  is  very  necessary;  for  if  there 

^Oppel:     Munch,  med.  Woch.,  Aug.  31,  1909. 

^Kansohoff:     Ann.  of  Surg.,  1910,  51,  453;    Lancet  Clinic,  Aug.   7,   1909. 


494 


ANESTHESIA 


is  pain  at  the  first  incision  the  patient  loses  confidence.    Anesthesia  thus 
produced  with  1 :  1000  cocain  plus  adrenalin  will  last  for  two  or  three 


Fig.   186. — Beginning  of  Skin  Wheal. 


hours.     If  the  method  of  Braun  is  used  and  the  incision  not  made  for 
some  minutes,  a  separate  injection  of  the  skin  is  not  necessary.     One  or 


Fig.   187. — Continuation  of  Wheal. 


more  small  wheals  are  raised,  and  through  these  anesthetic  areas  the 
subcutaneous  and  deeper  tissues  are  injected,  thus  affecting  the  nerves 


LOCAL  ANESTHESIA 


495 


before  they  reach  the  skin.   All  injections  should  be  made  slowly,  as  rapid 
distention  of  sensitive  tissue  is  always  painful. 


Fig.  188. — Congestion  of  Wheal  and  Beginning  of  Deep  Injection. 


The  subcutaneous  fat  is  sensitive  only  in  the  vessels  and  nerve  trunks 
which  traverse  it.  Therefore,  after  the  skin  incision  is  made,  these 
structures  may  be  sepa- 
rately injected  and  di- 
vided. Before  a  clamp  is 
applied  to  any  such  vessel 
or  nerve  an  injection 
should  be  made  about  it, 
for  pinching  is  more  pain- 
ful than  cutting.  With 
this  technique  absolutely 
painless  removal  of  such 
benign  skin  lesions  as  se- 
baceous cysts,  warts,  moles, 
scars,  lipomata,  etc.,  can 
be  accomplished.  With 
B  r  a  u  n's  circumscribing 
method  it  is  necessary  to 
wait  for  some  time,  while 
the  layer  method  permits 
immediate  incision,  an  ad- 
vantage in  minor  work.  Wliere  a  tumor  is  to  be  shelled  out  by  blunt 
dissection,  and  retraction  of  the  surrounding  tissues  is  required,  Braun's 


£ 


Fig.  189. — Anesthetization  of  Skin  by  Subcu- 
taneous Injection,  Showing  the  Wide  Area 
OF  Distribution  Through  Two  Injection 
Points.  ("The  American  Practice  of  Surgery," 
Vol.  IV.) 


496 


ANESTHESIA 


method  is  most  useful.  Here  again  it  must  be  urged  that  the  essentials 
for  painless  work  are  abundance  of  the  anesthetizing  solution  and  a  suffi- 
cient interval  between  its  injection  and  the  commencement  of  the  opera- 
tion. Immediate  injection  into  inflamed  skin  is  extremely  painful.  In 
anesthetizing  such  areas  it  is  important  to  make  the  first  injection  at 
some  distance  in  normal  skin  and  slowly  approach  the  tender  region, 
or  to  completely  surround  the  inflamed  part  with  the  injection  with- 
out touching  it,  thus  blocking  the  nerves  at  a  distance.  In  this  way 
localized  infections  may  be  completely  excised,  or  abscesses  opened  and 
drained. 


Fig.  190. — Injection  of  the  Deeper  Structures  Through  the  Same  Points  as  in 
Figure  189.  The  arrows  represent  the  needle  passing  in  various  directions  through 
skin,  subcutaneous  tissue,  and  muscle,  to  the  periosteum.  (After  Braun.  "The  Amer- 
ican Practice  of  Surgery,"  Vol.  IV.) 

Head  and  Neck. — In  the  surgery  of  the  head,  face,  and  neck,  with 
special  applications  in  the  throat,  nose,  eye,  ear,  and  teeth,  local  anes- 
thesia has  a  very  wide  field  of  usefulness.    Attention  to  the  nerve  supply 
will  make  possible  the  performance   of  many  extensive  operations  in 
which  general  narcosis  is  ordinarily  required. 

The  scalp  with  its  underlying  fascia  and  periosteum  receives  its  whole 
nerve  supply  from  below,  hence  it  is  possible  to  render  insensitive  con- 
siderable areas  by  injecting  subcutaneous  cross  strips  below  the  proposed 
seat  of  operation.  Ordinary  scalp  wounds  may  be  repaired  by  infiltrat- 
ing about  them;  and  sebaceous  cysts  and  other  benign  growths  removed 
by  infiltration  or  circumscribing  injection.  If  the  periosteum  is  sepa- 
rately injected  and  reflected,  tlie  skull  may  be  painlessly  opened  and  the 
surface  of  the  brain  examined  or  even  its  depths  explored.  The  jarring 
of  the  chisel  and  mallet  is  unpleasant,  but  not  painful,  as  I  have  demon- 
strated many. times  in  removing  osteophytes;  but  the  bone-drill,  Gigli 
saw,  or  rongeur  forceps  do  not  cause  any  complaint.  The  brain  sub- 
stance and  the  dura  show  no  evidence  of  sensibility  to  operative  manipu- 
lation. The  treatment  of  the  ordinary  compound,  depressed  fracture, 
without  loss  of  consciousness,  is  easy  and  satisfactory  by  anesthetizing 


LOCAL  ANESTHESIA 


497 


simply  the  scalp  and  periosteum.  Gushing  ^  has  reported  the  painless 
removal  of  a  large  subcortical  cyst  without  any  anesthetic,  the  bone  flap 
having  been  freed  at  a  previous  sitting.  Extensive  use  of  cocain  in  the 
scalp  was  formerly  feared  because  of  the  danger  of  absorption,  but  with 
the  modern  pneumatic  tourniquet  or  with  adrenalin  added  to  the  solu- 
tion there  is  practically 
no  risk  in  using  large 
amounts  of  cocain  or 
novocain.  In  cases  of 
delirium  or  great  irri- 
tability, head  injuries 
had  best  be  treated  with 
a  general  anesthetic. 

Face. — The  face  of- 
fers many  possibilities 
for  the  local  methods. 
The  definite  supply  of 
the  fifth  nerve,  with  ac- 
cess to  its  branches  at 
their  exit,  makes  the 
anesthetization  of  its  dis- 
tribution an  attractive 
field  for  nerve  blocking. 
The  supra-orbital,  infra- 
orbital, and  inferior  den- 
tal are  readily  attacked 
at  their  respective  fora- 
mina. Plastic  operations 
about  the  outer  ear,  the 
mouth,  nose,  and  eyelids 
are  easily  executed  with 

the  aid  of  simple  infiltration,  and  we  now  do  in  office  practice  the 
majority  of  operations  formerly  requiring  general  narcosis.  Post- 
operative pain  is  delayed  long  enough  to  enable  the  patient  to  return 
to  his  home  and  get  comfortably  settled.  A  knowledge  of  anatomy  and 
nerve  supply  will  make  possible  most  extensive  procedures,  as  has  been 
so  ably  demonstrated  by  Matas  in  the  painless  partial  excision  of  both  su- 
perior maxillae  by  blocking  the  nerves.  Partial  removal  of  the  tongue,  the 
cheeks,  or  gums  can  be  done  under  infiltration  or  by  blocking  the  lingual 
and  inferior  dental  nerves.  The  technique  of  blocking  the  individual 
branches  of  the  fifth  nerve  will  be  found  in  the  works  of  OfEerhaus,^ 


Fig.  191.— Nerve  Supply  of  Face  and  Scalp  from 
THE  Cervical  Plexus  and  Trigeminal  Nerve. 
1,  N.  frontalis;  2,  n.  supraorbi talis;  3,  n.  zygo- 
matico-temporalis  (trigeminus  II) ;  4,  n.  auriculo- 
temporalis  (trigeminus  III) ;  5,  n.  auricularis  mag- 
nus;  6,  n.  occipitalis  minor;  7,  n.  occipitalis  major; 
8,  n.  supra-  and  intratrochlearis;  9,  n.  infraorbitalis; 
10,  ramus  nasalis  ext.  nervi  ethmoidalis ;  11,  n. 
metalis.  (After  Braun.  "The  American  Practice 
of  Surgery,"  Vol.  IV.) 


*  Gushing:     J.  Am.  Med.  Assn.,  1908,  50,  847. 
''Offerhaus:     Arch.  f.  Uin.  CUr.,  1910,  92,  1. 


498 


ANESTHESIA 


Braun/  and  Haertel,^  who  describes  the  anatomic  approach  to  the  Gasser- 
ian  ganglion  by  needle  puncture.  The  ganglion  is  reached  through  the 
foramen  ovale,  and  injected  with  1  c.  c.  of  2  per  cent  novocain-suprarenin 
solution,,  obtaining  almost  immediately  anesthesia  which  lasts  about  an 
hour  and  a  half.    Haertel  reports  16  operations  by  this  method,  including 

six  resections  of  the  upper 
jaw,  three  of  the  lower  jaw, 
and  two  of  the  tongue. 
Braun  states  that  under 
local  anesthesia  resection  of 
the  upper  jaw  has  quite  lost 
its  danger.  Of  ten  patients 
he  has  lost  none,  and  had 
no  pulmonary  complica- 
tions. Haertel  reports  nine 
with  equal  success.  The 
application  in  dentistry  is 
given  in  detail  in  another 
section.  The  lower  jaw  can 
be  reached,  for  wiring  of 
fractures,  by  infiltration 
with  a  separate  injection  of 
the  periosteum,  and  great 
assistance  may  be  had  from 
the  blocking  of  the  inferior  dental  nerve.  Perineural  injection  at  the 
mental  foramina  with  submental  infiltration  will  enable  one  to  remove 
a  growth  on  the  lower  lip  with  its  area  of  lymphatic  drainage.  In  elderly 
persons  it  is  a  distinct  advantage  to  carry  out  this  procedure  without  a 
general  anesthetic.  The  cervical  lymph  nodes  can  thus  always  be  re- 
moved. The  best  routine  technique  is  to  first  distribute  in  the  sub- 
mental and  submaxillary  regions  a  liberal  infiltration  of  0.5  per  cent 
novocain-suprarenin  solution,  and  then  proceed  with  the  excision  of  the 
lip.  By  the  time  this  is  completed  and  the  gloves  are  changed,  anesthe- 
sia in  the  neck  is  so  well  established  that  the  dissection  can  be  carried  out 
at  will. 

Ear. — The  ear,  as  far  as  its  external  part  is  concerned,  can  be  anes- 
thetized by  injections  through  two  points,  one  close  to  the  superior  at- 
tachment of  the  auricle  and  one  below  the  lobule  in  the  furrow  between 
the  mastoid  process  and  the  articulation.  From  these  two  points  the 
fluid  is  injected  subcutaneously  and  along  the  wall  of  the  external  audi- 
tory canal.    This  often  produces  anesthesia  of  the  drumhead  as  well.    A 

^  Braun:     " Lokalansesthesie, "  3rd  edition,  Leipzig,  1913. 
-Haertel:      VerJiandl.  d.  deutsch.   Gesellsch.  f.  Chir.,  1911,  1,  243;   also  Arch. 
f.  Tclin.  Chir.,  1912,  100,  193. 


Fig.  192. — Showing  the  Area  of  Anesthesia 
Produced  by  a  Cross  Strip  of  Subcutaneous 
Injection  Above  the  Supra-Orbital  Ridge, 
Blocking  the  Nerve  Supply  from  Below. 
(After  Braun.  "The  American  Practice  of  Sur- 
gery," Vol.  IV.) 


LOCAL  ANESTHESIA 


499 


solution  of  cocain  (1  per  cent)  and  adrenalin  applied  on  a  piece  of  cot- 
ton to  the  drumhead  for  ten  or  fifteen  minutes  will  give  a  sufficient  anes- 
thesia for  paracentesis. 

The  mastoid  process  can  be  operated  upon  by  periosteal  injection, 


Fig.  193. — Sensory  Innervation  of  the  Mucous  Membranes  of  the  Head.  The 
areas  supplied  by  the  various  cranial  nerves  are  indicated  by  the  numbers  of  the 
nerves.     (After  Hasse.     Haertel  in  Arch,  f.klin.  Chir.,  1912.) 


and  in  1908  forty  cases  were  reported  from  Politzer's  clinic,  in 
which  the  radical  operation  was  thus  done.^  Unless  there  is  some  con- 
traindication, operations  upon  the  mastoid  should  be  left  to  general 
anesthesia. 

Nose  and  Accessory  Sinuses,  Tonsils. — In  the  treatment  of  affections 
of  the  nose  and  accessory  sinuses  cocain  occupies  a  unique  position, 
producing  not  only  satisfactory  anesthesia,  but,  by  contracting  the  mu- 
cous membranes,  permitting  thorough  examination  and  local  treatment. 
It  is  applied  on  cotton  soaked  with  the  solution  and  left  in  place  for 

'Haymann:     Zentralbl.  f.  OhrenheiW.,  1908,  6,  203. 


500 


ANESTHESIA 


from  five  to  fifteen  minutes.     The  solution  ordinarily  used  is   5   per 
cent  cocain  plus  adrenalin;  but  rhinologists  are  tending  now  to  weaker 

1 


Fig.  194. — Sagittal  Section  through  the  Foramen  Ovale.  The  section  repre- 
sents a  somewhat  obliquely  placed  vertical  plane  corresponding  to  the  cannula  in- 
serted in  the  Gasserian  ganglion.  (1)  Gasserian  ganglion  fossa;  (2)  Porous  portion 
of  temporal  bone;  (3)  Carotid  canal;  (4)  Occipital  bone;  (5)  Anal  wing  of  sphenoid; 
(6)  Infratemporal  plane;  (7)  Cannula  in  foramen  ovale.  (Haertel  in  Arch.  f.  klin. 
Chir.,  1912.) 

solutions,  for  the  same  results  can  be  obtained  with  1  per  cent  cocain, 
except  that  a  longer  period  of  waiting  is  required.     Enucleation  of  the 

tonsils  is  in  most  cases 
readily  accomplished  by  a 
thorough  infiltration  of 
the  peritonsillar  area.  It 
has  been  claimed  that 
there  is  greater  tendency 
to  bleeding  after  tonsillec- 
tomy with  cocain  and  ad- 
renalin, and  the  method 
has  therefore  met  with 
some  opposition.  Hertz- 
ler  ^  makes  a  strong  plea 
for  the  use  of  quinin  and 
urea  hydrochlorid,  claim- 
ing that  it  lessens  the  dan- 
ger of  post-operative  hem- 
orrhage. 

Eye. — The  eye  was  the 
site  of  the  first  practical 
use  of  cocain.    In  many  operations  upon  this  organ  narcosis  has  distinct 
^Hertzler:     Am.  J.  of  Surg.,  1911,  24,  351. 


Fig.  195. — Position  and  Size  of  Skin  Wheal  for 
Puncture  of  Gasserian  Ganglion.  (Haertel 
in  Arch.  f.  klin.  Chir.,  1912.) 


LOCAL  ANESTHESIA 


501 


disadvantages,  and  must  be  very  deep  in  order  to  destroy  sensation. 
Again  the  active  cooperation  of  the  patient  is  often  desirable.  The 
greater  number  of  all  operations  are  therefore  done  under  local  anes- 


FiG,  196.— Front  and  Side  Views  Showing  the  Direction  of  the  Cannula  to  Reach 
THE  Gasserian  Ganglion  ACCORDING  TO  Haertel's  Method.  From  the  front  the 
cannula  points  toward  the  eye ;  from  the  side  toward  the  auricular  process  of  the  malar 
bone.     (Haertel  in  Arch.  f.  klin.  Chir.,  1912.) 

thesia.  Two  to  five  per  cent  solutions  of  cocain  are  used,  and  are  applied 
by  dropping  into  the  eye — instillation.  Adrenalin  increases  and  pro- 
longs the  action  of  the  cocain.  Subconjunctival  injections  are  used  in 
extensive  operations,  and  enucleation  of  the  eye  can  be  painlessly  done.^ 

Neck. — The  greater  part  of 
the  sensation  of  the  skin  and  sub- 
cutaneous tissue,  the  fascia  and 
muscles  of  the  anterior  part  of 
the  neck,  is  supplied  by  the 
branches  of  the  cervical  plexus, 
which  can  readily  be  reached 
along  the  posterior  border  of  the 
sternomastoid  muscle.  The  in- 
filtration method,  however,  finds 
here  a  most  extensive  field  of  use- 
fulness. Ligation  of  any  of  the 
great  vessels  can  be  done  with  the 
greatest  ease.  Benign  tumors  can 
be  removed  and  individual  glands 
or  groups  of  glands  excised. 
Complete  excision  of  all  the 
glands  is  difficult  but  possible. 
I  have  done  this  several  times 
aided    by   layer    infiltration,    the 

*Vail:     J.  of  Ophthal 


FiG.  197. — Area  of  Anesthesia  Produced 
BY  Blocking  the  Cervical  Plexus  at 
the  Posterior  Border  of  the  Sterno- 
mastoid Muscle.  (After  Braun.  "The 
American  Practice  of  Surgery.") 


by   blocking   of   the    cervical   plexus 
dissection   being    carried    along    the 
and  Oto-Laryngol.,  Aug.,  1911. 


502  ANESTHESIA 

jugular  vein  from  the  clavicle  to  the  skull.  Such  dissections,  however, 
are  tedious,  and  unless  there  is  some  absolute  contraindication,  general 
narcosis  is  much  to  be  preferred.  In  extensive  malignant  disease,  as  for 
Crile's  block  dissection,  local  anesthesia  should  not  be  considered. 

Tracheotomy. — In  adults  tracheotomy  is  by  choice  an  operation  for 
local  anesthesia  by  infiltration.  The  trachea  being  opened  and  its  mu- 
cous membrane  sprayed  with  cocain,  it  is  possible  to  explore  its  lower 
portion  and  even  the  bronchi.  The  cooperation  of  the  patient  may  in 
this  way  be  of  great  assistance  in  the  expulsion  of  foreign  bodies,  so 
that  they  may  be  removed  through  the  tracheal  incision. 

Larynx. — In  operative  procedures  upon  the  larynx  general  narcosis 
has  particular  disadvantages  which  may  be  avoided  by  the  use  of  cocain. 
Crile  ^  has  demonstrated  that  the  reflex-carrying  power  of  the  superior 
laryngeal  nerve  may  be  abolished  by  spraying  the  mucous  membrane 
with  cocain;  or  the  nerve  may  be  reached  by  infiltration  about  the  tip 
of  the  posterior  cornu  of  the  hyoid  bone.  The  larynx  is  readily  exposed 
by  infiltration,  and  may  be  partially  or  totally  extirpated. 

Thyroid. — Kocher,  Eoux,  Bier,  and  others  complete  the  majority  of 
operations  upon  the  thyroid  gland  under  local  anesthesia,  and  Kocher 
assigns  his  low  mortality  in  great  part  to  this  fact.  Mayo,  on  the  other 
hand,  with  his  wonderful  results,  rarely  uses  local  methods.  With  the 
recent  improvement  in  the  administration  of  general  anesthetics  the 
choice  is  not  so  important  as  it  was  a  few  years  ago,  when  deaths  under 
general  anesthesia  in  goiter  operations  were  not  uncommon.  If  one 
will  have  the  patience  to  work  out  the  details  of  operations  under  the 
local  methods  in  a  few  of  these  cases,  he  will  be  impressed  with  the  case 
with  which  seemingly  difficult  ones  can  be  handled,  and  many  a  poor 
operative  risk  may  thus  be  brought  within  the  lines  of  safety.  In 
hyperthyroidism  this  is  especially  applicable.  These  very  nervous  pa- 
tients seem  to  be  particularly  amenable  to  the  application  of  the  local 
methods,  and  it  is  surprising  to  see  how  well  they  stand  even  extensive 
operations  when  aided  by  a  preliminary  dose  of  morphin  or  scopolamin. 

The  ligation  of  the  thyroid  arteries  in  such  cases  should  always  be 
done  under  local  anesthesia.  Crile  often  performs  these  operations  with- 
out removing  the  patients  from  bed.  For  the  ligation  of  the  superior 
thyroid  arteries,  or,  rather,  of  the  superior  poles,  on  both  sides,  a  single 
transverse  line  of  skin  incision  about  two  and  a  half  inches  in  length 
crossing  the  central  part  of  the  thyroid  cartilage  is  infiltrated.  Through 
this  a  deep  injection  is  made  on  either  side.  The  incision  is  carried 
through  skin  and  platysma  muscle.  The  inner  border  of  the  sterno- 
mastoid  is  retracted  outward,  the  omohyoid  inward  and  upward,  thus 
exposing  the  superior  pole  of  the  gland.  A  linen  thread  is  passed 
around  the  pole,  including  all  its  vessels.     Before  this  is  tied  it  is  well 

^  Crile,  Geo.  W.:     The  Laryngoscope  (St.  Louis),  Dec,  1912. 


LOCAL    ANESTHESIA 


503 


to  inject  a  few  drops  of  1  per  cent  cocain  aljout  the  pole,  as  the  tighten- 
ing of  the  ligature  is  often  painful.  The  inferior  arteries  can  best  be 
approached  at  the  posterior  border  of  the  sternomastoid  muscle  just 
above  the  clavicle,  as  recommended  by  Kogers,  the  artery  thus  being 
secured  before  it  passes  behind  the  carotid.  This  method  will  be  found 
much  more  satisfactory  than  exposing  the  artery  anterior  to  the  caro- 
tid, which  necessitates  greater  retraction  and  more  or  less  delivery  of  the 
thyroid  gland.  A  separate  transverse  incision  is  made  for  each  artery, 
and  the  ligation  is  done  with  practically  no  pain. 

In  operations  upon  the  gland  itself  for  the  partial  or  complete  re- 


FiG.  198. — Blocking  the  Cervical  Plexus  at  Posterior  Border  of  Sternomastoid 

Muscle. 


section  of  a  lobe  or  for  the  removal  of  cysts  or  other  tumors,  the  trans- 
verse collar  incision  is  ordinarily  used.  In  this  operation  one  may 
either  anesthetize  by  Braun's  method  or  by  layer  infiltration.  Bier  ^  de- 
scribes his  procedure  as  follows:  "Through  anesthetic  skin-wheals 
a  subcutaneous  injection  of  the  field  of  operation  is  made  in  the  form 
of  a  quadrant.  Then  the  needle  is  carried  obliquely  under  the  fascia 
along  the  border  of  the  sternomastoid,  constantly  injecting  in  the  direc- 
tion of  the  great  vessels  without  reaching  them.  The  needle  is  intro- 
duced upward  and  downward  imder  the  fascia,  and  in  deeply  situated 
goiters  the  injection  is  carried  behind  the  sternum.  Finally  the  isthmus 
is  injected.  ISTaturally  the  needle  cannot  be  passed  all  the  way  be- 
hind the  goiter,  but  with  sufficiently  generous  use  of  the  fluid  (60  to 
80  c.  c.  of  0.5  per  cent  novocain  plus  adrenalin)  it  diffuses  everywhere. 
^  Bier :     ArcMv  f.  Iclin.  Chir.,  1909,  40,  349. 


504 


ANESTHESIA 


At  times  even  the  recurrent  laryngeal  may  be  paralyzed  by  the  novocain. 
The  important  point  now  is  to  wait  a  sufficient  time  before  beginning 
the  operation,  when  the  goiter  can  usually  be  removed  without  any  com- 
plaint of  pain.'^ 

Another  method  which  has  proven  quite  satisfactory  is  the  fol- 
lowing. The  line  of  incision  is  infiltrated  with  cocain  (1:1000-|- 
adrenalin).  Through  this  a  subcutaneous  injection  of  a  weaker  solu- 
tion (1 :  2000  4"  adrenalin)  is  carried  well  above  and  below,  into  and 
under  the  platysma.^  An  injection  of  1  per  cent  cocain  is  now  made 
along  the  posterior  .border  of  the  sternomastoid  to  surround  the  branches 


Fig.  199.- 


-Incision  Through  Skin  and  Platysma  Muscle  Showing  Almost  Blood- 
less Field. 


of  the  cervical  plexus.  This  greatly  lessens  the  dragging  discomfort  so 
often  described  when  retraction  is  made  or  the  gland  delivered.  The  in- 
cision through  the  skin  and  platysma  is  made,  a  separate  injection  being 
done  about  each  vessel  of  any  size  before  clamping.  The  muscles  are 
then  retracted  or  divided  and  the  goiter  exposed.  An  injection  of  the 
weaker  solution  is  now  made  all  about  the  gland,  especially  about  its 
upper  pole.  As  a  rule,  no  further  application  of  the  anesthetic  is  re- 
quired. It  must  be  borne  in  mind  that  the  chief  sensitive  areas  encoun- 
tered in  the  actual  cutting  part  of  the  operation  are  the  skin  and  the 
vessels,  and  that  the  procedure  most  likely  to  cause  pain  is  retraction. 
The  gland  itself  is  not  sensitive,  and,  once  exposed,  tumors  may  be  pain- 
lessly enucleated  from  it  or  portions  of  it  excised  at  will.    Braun  reports 

*See  Figures  186,  187,  and  188. 


LOCAL    ANESTHESIA 


505 


that  from  1908  to  1911  his  150  thyroidectomies  have  without  exception 
been  done  under  local  anesthesia. 

The  possibilities  of  extensive  operative  work  in  the  neck  have  been 
greatly  increased  by  the  introduction  of  the  novocain-suprarenin  solution, 
because  of  the  enormous  amount  of  the  solution  which  can  be  used  with 
safet}''.  The  special  importance  of  the  combination  of  local  and  general 
anesthesia  in  surgery  of  the  neck  has  been  emphasized  by  Crile.^ 

Thorax  and  Breast. — There  are  two  operations  in  the  region  of  the 
thorax  which  in  our  clinic  are  always  done  under  local  anesthesia,  ex- 
cept in  very  young  children :  wiring  of  a  fractured  clavicle  and  resection 


Fig.  200. — Operation  Completed;  Wound  Closed. 


of  a  rib  for  empyema  or  the  drainage  of  abscess  of  the  lung.  Other 
minor  procedures,  as  tapping  the  pericardium  or  aspiration  of  the 
pleura,  so  often  accomplished  at  the  expense  of  great  pain,  may  be  ren- 
dered perfectly  painless  by  the  judicious  injection  of  a  local  anesthetic. 
Where  an  aspirating  needle  is  introduced  in  an  intercostal  space  through 
a  frozen  point  on  the  skin  there  may  be  intense  pain  if  it  happens  to 
strike  the  periosteum  or  an  intercostal  nerve  or  vessel,  and  there  is  al- 
ways pain  when  the  parietal  pleura  is  reached.  The  course  of  the  needle 
may  be  completely  anesthetized  by  first  injecting  the  skin  and  then  dis- 
tributing a  liberal  amount  of  a  weak  solution  in  the  intercostal  space 
and  about  the  ribs  or  in  the  periosteum  and  finally  in  the  pleura.  A 
fairly  long  needle  is  used  and  the  injection  kept  up  continuously  as  the 
needle  is  pushed  in  until  the  pleura  is  reached.  It  does  not  matter  if  the 
pleura  is  penetrated  by  the  needle. 

In  the  excision  of  a  rib  the  injection  may  be  made  in  the  same  way 
^Crile:     Jour.  Am.  Med.  Assn.,  1912,  59,  114. 


506  ANESTHESIA 

or  the  tissues  may  be  injected  layer  by  layer  as  encountered.  When  the- 
periosteum  is  reached,  it  is  given  a  separate  thorough  injection,  then  in- 
cised and  reflected.  The  division  of  the  rib  denuded  of  periosteum  is 
absolutely  painless.  The  parietal  pleura  is  quite  sensitive,  and  requires 
a  separate  injection,  but  the  lung  and  visceral  pleura  are  not  sensitive 
and  may  be  painlessly  incised  or  punctured. 

A  fractured  clavicle  may  be  exposed  for  wiring  in  just  the  same  way. 
Its  periosteum  being  thoroughly  anesthetized,  no  pain  is  caused  by  the 
adjustment,  drilling,  and  fixation  of  the  fragments.  As  immediate  anes- 
thetization is  desirable  and  the  amount  used  is  small,  1  per  cent  cocain  is 
advised,  or  a  liberal  injection  of  the  whole  neighborhood  of  the  fracture 
with  0.5  per  cent  novocain-suprarenin  after  a  few  minutes  will  yield  a 
painless  operative  field.  In  complicated  fractures  with  several  fragments, 
perfect  reduction  can  be  obtained,  and  a  much  simpler  and  more  com- 
fortable dressing  may  be  applied.  As  there  is  no  need  of  forced  restraint 
to  overcome  displacement,  the  forearm  may  be  left  free  and  the  period 
of  disability  is  materially  lessened.  The  results  of  this  procedure  have  been 
most  gratifying,  and  its  ease  and  simplicity  are  strong  recommendations. 
With  careful  suturing  of  skin  and  subcutaneous  tissue  the  resulting  scar 
is  almost  unnoticeable. 

The  breast  is  a  poor  field  for  local  anesthesia.  Its  nerve  supply  is 
diffuse  and  abundant.  Small  benign  tumors  can  be  removed  by  a  diffuse 
circumscribing  injection,  and  exploratory  incisions  may  be  made  or  ab- 
scesses opened  in  the  same  way.  The  whole  breast  can  be  excised  by  an 
extensive  infiltration  beneath  and  around  it ;  but  large  amounts  of  fluid 
are  necessary,  and  absorption  is  rapid.  Malignant  growths  should  always 
be  operated  under  general  anesthesia. 

In  the  axilla,  individual  glands  and  small  tumors  or  abscesses  may  be 
treated  as  in  the  other  parts  of  the  body ;  but  in  extensive  dissections,  be- 
cause of  the  rich  and  diffuse  nerve  supply  and  the  necessarily  painful 
traction  on  unanesthetized  tissues,  general  anesthesia  is  indicated. 

The  Extremities. — Until  the  introduction  of  the  intravenous  and 
intra-arterial  methods  the  extremities  were  fruitful  fields  for  the  appli- 
cation of  neuro-regional  anesthesia.  Both  perineural  and  endoneural 
injections  found  suitable  regions,  and  by  a  combination  of  these  with 
infiltration  almost  any  operation  upon  the  extremities  was  made  possi- 
ble. The  intravenous  and  arterial  methods  are  so  simple  and  safe  that 
to  a  large  extent  they  will  probably  supplant  the  more  complicated  pro- 
cedures, and  the  anesthesia  obtained  by  them  is  so  satisfactory  that  many 
operations  are  made  easy  which  previously  offered  serious  technical  diffi- 
culties. The  technique  has  already  been,  given.  In  many  cases  the  older 
methods  may  be  simpler  and  more  suitable. 

The  brachial  plexus  may  be  exposed  at  the  scalini  and  blocked  by 
direct  injection,  thus  making  possible  amputations  or  other  operations 


LOCAL    ANESTHESIA 


507 


in  any  part  of  the  arm.  Crile  ^  has  thus  done  a  shoulder-girdle  amputa- 
tion. Kulenkampff "  has  described  a  method  by  wliich  he  reaches  the 
plexus  above  the  clavicle  without  incising  the  skin.  He  gives  anatomic 
details,  and  reports  25  cases,  in  only  three  of  which  was  a  little  ether 
necessary.  In  the  arm  the  large  nerve  trunks  may  be  exposed  and  in- 
jected, obtaining  anesthesia  in  the  areas  of  their  distribution.  This 
can  be  done  most  readily  at  the  elbow.  The  nerves  of  the  arm  are  accessi- 
ble also  for  perineural  injection  at  various  points.  The  median  nerve 
may  be  reached  at  the  wrist  by  introducing  the  needle  on  the  ulnar  side 
of  the  tendon  of  the  palmaris  longus  and  passing  obliquely  beneath  this 


Millie. 


uilerosseiis  cfors 


(/oj 


J^iiL 


^^'  ,jVr.H/ijL 


IS 


'/ItlJf^ 


'^m/l 


IS 


-    .Af //rjror  m^/m^/S 


Fig.  201. — Cross-section  of  Forearm,  5  cm.  above  the  Wrist.  The  arrows  indicate 
the  direction  of  the  needle  in  reaching  the  median  and  ulnar  nerves  for  perineural  in- 
jection.    (After  Braun.     "The  American  Practice  of  Surgery,"  Vol.  IV.) 


tendon  toward  the  radius,  a  distance  of  1  or  2  cm.  The  radial  nerve 
may  be  blocked  by  subcutaneous  injection.  The  ulnar  nerve  may  be  ap- 
proached a  couple  of  inches  above  the  wrist  by  the  needle  passing  between 
the  ulna  and  the  tendon  of  the  flexor  carpi  ulnaris.  Minute  details  of 
the  anesthesia  obtained  by  injection  at  various  points  are  given  by 
Braun.^ 

One  of  the  most  common  applications  of  the  perineural  method  is  in 
the  anesthetization  of  an  individual  finger  or  toe.  Each  finger  is  sup- 
plied by  four  sensory  nerves,  two  anterior  and  two  posterior.  These  can 
be  surrounded  by  the  solution  through  two  punctures  at  the  base  of  the 
finger  on  the  dorsal  aspect,  the  needle  being  carried  close  to  the  bone. 
The  strong  solution  (1  per  cent)  is  used,  and  in  a  few  minutes  the  whole 
finger  can  be  rendered  insensitive.  Injections  betwen  the  metacarpals 
will  produce  anesthesia  of  the  fingers  and  metacarpal  region  as  well. 

*  Crile:     J.  Am.  Med.  Assn.,  1902,  38,  491. 

=■  Kulenkampflf :     ZentraTbl.  f.  CMr.,  1911,  38,  1337. 

*  Braun:     "Die  Lokalanaesthesie,  "  Leipzig,   1913. 


508 


ANESTHESIA 


Many  operations  on  the  extremities  can  be  done  by  infiltration  alone. 
Lerda  ^  reports  a  method  for  the  painless  reduction  of  fractures  by  in- 
jecting the  region  of  the  fracture  freely  with  a  weak  solution  of  cocain 
and  adrenalin  by  means  of  a  long  needle.  Anesthesia  is  complete  in 
8  to  10  minutes,  and  in  30  cases  there  was  no  pain  during  the  reduction 


Fig.  202. — Distribution  op  the  Nerves  of  the  Upper  Extremity  to  the  Skin  An- 
teriorly AND  Posteriorly.  1,  Supraclaviculares;  2,  cutaneus  brachii  medialis;  3, 
cutaneus  brachii  anterior;  4,  cutaneus  antebr.  med.;  5,  cutaneus' antebr.  lateralis;  6, 
cutaneus  antebr.  dorsalis;  7,  radialis  superficialis ;  8,  ramus  palmaris  n.  mediani; 
9,  ramus  palmaris  n.  ulnaris;  10,  ramus  dorsalis  n.  ulnaris;  11,  n.  ulnaris;  12,  n.  medi- 
anus;  13,  cutaneus  brachii  lateralis.  (After  Braun.  "The  American  Practice  of 
Surgery,"  Vol.  IV.) 


of  the  fragments.  Where  wiring  or  plating  is  indicated  the  bone  may 
in  many  instances  be  exposed  by  infiltration  and  the  periosteum  freely 
injected,  when  reduction  can  be  painlessly  done.  This  is  especially  true 
of  the  olecranon  and  patella,  which  we  attack  as  a  matter  of  routine  un- 
der local  anesthesia.  The  tibia  also  lends  itself  readily  to  such  treat- 
ment, and  the  radius  and  ulna  often  without  much  difficulty.  With  the 
addition  of  nitrous  oxid  at  the  moment  of  reducing  the  fragments,  very 
extensive  fractures  may  be  fixed.  In  an  old  lady  of  85  years  with  an 
'Lerda:     Zentralb.  f.  Chir.,  1908,  34,  1417. 


LOCAL    ANESTHESIA 


509 


?  .- 


oblique  fracture  of  the  shaft  of  the  femur,  I  v/as  able  to  expose  the  seat 
of  fracture  painlessly  by  iufiltratioji.  She  was  then  given  a  few  whiffs 
of  nitrous  oxid  while  the  greatly 
displaced  fragments  were  brought 
into  line  and  secured  with  a  clamp. 
During  the  drilling  and  application 
of  a  Lane  plate  and  screws  she  was 
conscious  and  talking,  but  felt  no 
pain.  She  was  gotten  up  in  a  chair 
on  the  following  day,  and  left  the 
hospital  in  six  weeks,  walking  with- 
out crutches  or  cane. 

Small  osteomyelitic  cavities  can 
be  painlessly  gouged  out  after 
thorough  injection  of  the  perios- 
teum. While  the  bone  substance  is 
insensitive,  the  medullary  cavity  of 
the  long  bones  is  sometimes  quite 
the  opposite.  By  means  of  the  in- 
travenous method  the  great  majority  of  fractures   of  the   extremities 


Fig.  203. — Cross-section  through  Base 
OF  Finger.  Showing  the  direction  of 
the  needle  in  anesthetizing  the  whole 
finger,  a,  Flexor  tendons;  b,  bone; 
c,  extensor  tendons.  The  nerves  are 
indicated  by  black  dots  according  to 
the  size  of  the  individual  trunks. 
(After  Braun.  "The  American  Prac- 
tice of  Surgery,"  Vol.  IV.) 


N.  peronaeus  superf. 
N.  peronaeus  prof  ^^ 


Extensor  hall. 


Extensor  di 


M.  peronaei  - 
Plexor  hall.  --    » 


"N.  suralis 


-Tibialis  pOSt 
Flexor  dig. 


Fig.  204. — Cross-section  through  Leg  Just  Above  Ankle,  Showing  Direction  of 
Needle  for  Perineural  Injection  of  Posterior  Tibial  Nerve.  (After  Braun. 
"The  American  System  of  Surgery,"  Vol.  IV.) 


510 


ANESTHESIA 


can  be  brought  under  the  domain  of  local  anesthesia  for  either  closed 
or  open  treatment. 


Fig.  205. — Injection  of  Skin  Incision  for  Hallux  Valgus. 

In  the  buttocks  and  upper  part  of  the  thigh,  local  methods  are  un- 
satisfactory because  of  the  diffuse  nerve  supply.     The  groin,  however,  is 


Fig.  2UG. — Daai'  Injection  Between  Metatausals. 

readily  invaded  by  means  of  diffuse  infiltratio]i,  and  a  complete  dissec- 
tion of  the  glands  of  this  region  is  not  difficult.     The  sciatic  and  other 


LOCAL    ANESTHESIA 


511 


nerves  of  the  leg  can  be  utilized  for  blocking  when  exposed  by  dissection. 
Skin  grafts  may  be  cut  from  the  antero-lateral  surface  of  the  thigh  by 
blocking  the  external  cutaneous  nerves.  The  posterior  tibial  nerve  can 
be  reached  for  perineural  injection  at  the  internal  malleolus  by  inserting 
the  needle  1  cm.  from  the  median  border  of  the  tendo  Achillis,  passing 
it  directly  forward  to  the  posterior  surface  of  the  tibia  and  then  with- 
drawing it  slightly  and  injecting  the  solution.     The  various  operations 


Fig.  207  — Injection  of  Periosteum. 


for  ingrowing  toe  nails  can  always  be  done  by  anesthetizing  the  toe,  as 
already  described.  The  operation  for  hallux  valgus  can  be  painlessly 
accomplished  by  an  injection  between  the  metatarsals.  Small  varices  can 
be  excised  by  infiltration,  and  by  the  intravenous  method  one  can  do  a 
complete  excision  of  varicose  veins  of  the  legs  by  the  open  method  or  by 
Mayo's  stripping  procedure.  By  this  method  also  all  resections  of  joints 
and  tendon  transplantation  are  possible.  It  must  be  remembered  when 
approaching  a  joint  by  layer  infiltration  that  synovial  membranes  are  ex- 
quisitely sensitive,  and  a  separate  anesthetization  is  necessary.  The  joint 
is  emptied  of  what  fluid  it  contains  by  aspiration,  and  is  refilled  through 
the  same  needle  with  1 :  1000  cocain  and  adrenalin,  or  0.5  per  cent  novo- 
cain. In  a  few  minutes  it  is  quite  insensitive  for  exploration  or  removal 
of  foreign  bodies,  etc.  Laewen^  in  1911  presented  the  technique  of 
^Laewen:     Deutseh.  Ztsclir.  f.  Cliir.,  1911,  3,  252. 


512 


ANESTHESIA 


reaching  by  puncture  the  various  nerves  of  the  leg.  Keppler  ^  in  1912 
gave  further  details  with  the  report  of  cases.  Babitzki^  recently  described 
a  method  of  reaching  the  sciatic  nerve  at  its  foramen,  controlling  the 
course  of  the  needle  by  a  finger  in  the  rectum. 

Genito-urinary  System. — In  this  field  of  surgery,  as  in  other  special- 
ties, it  has  been  the  custom  in  the  past  to  use  unnecessarily  strong  solu- 


FiG.  208. — Resection  of  Bone. 


tions.  The  urethra  can  be  anesthetized  by  applying  1  per  cent  cocain 
plus  adrenalin  and  the  bladder  by  running  into  it  1 :  1000  cocain  and 
adrenalin,  or  0.5  per  cent  novocain-suprarenin.  It  is  necessary  to  wait 
a  few  minutes  to  obtain  anesthesia.  The  introduction  of  instruments  for 
exploration  or  treatment  is  then  free  from  pain.  Internal  urethrotomy 
is  much  more  painful  than  gradual  dilatation.  External  urethrotomy  by 
infiltration  is  quite  satisfactory.     In  suprapubic  cystotomy  the  bladder 

^Keppler:      Arch.   f.  Chir.,   1912,  .^6161,   501. 
='Babitzki:     Zentralbl.  f.  CUr.,  1913,  40,  227. 


LOCAL    ANESTHESIA 


513 


should  first  be  anesthetized  and  the  suprapubic  opening  made  by  means 
of  infiltration.  Tinker  ^  has  been  able  to  accomplish  perineal  prostatec- 
tomy by  means  of  infiltration  and  blocking  of  the  perineal  nerves,  and 
Lanz  ^  reports  similar  work.  Franke  and  Posner  "  present  a  study  of 
the  sensory  nerves  of  the  pelvis  and  perineum  with  the  technique  of 
reaching  them  by  puncture.  They  report  ten  prostatectomies  by  their 
method,  all  accomplished  under  absolute  anesthesia.     The  scrotal  con- 


FiG,  209. — Insertion  of  Fascial  Flag. 


tents  can  be  satisfactorily  anesthetized  by  a  thorough  injection  of  the 
cord  at  or  below  the  external  ring.  All  operations  for  hydrocele  or  vari- 
cocele thus  belong  to  the  routine  local  anesthesia  group. 

Circumcision. — Circumcision  in  adults,  likewise,  belongs  to  the  same 
class,  and  may  be  considered  an  oifice  operation.  In  children  it  is  more 
difficult,  the  youngest  in  my  experience  being  a  boy  5  years  of  age.  The 
mucous  membrane  may  be  partially  anesthetized  by  filling  the  prepuce 
with  1  per  cent  cocain  and  adrenalin  and  waiting  a  few  minutes.  The 
line  of  skin  incision  is  then  injected  with  the  weak  solution,  the  incision 

*  Tinker:     Jour.  Am.  Med.  Assn.,  1905,  44,  471. 

^Lanz:     JDeut.  med.  Woch.,  1905,  34,  953. 

^Franke  and  Posner:     Arch.  f.  Idin.  Chir.,  1912,  49,  139. 


514 


ANESTHESIA 


made,  and  the  skin  reflected.  The  mucous  membrane  is  now  injected 
with  the  same  solution,  the  needle  being  introduced  from  the  skin  side. 
The  mucous  membrane  is  slit  up  the  dorsum  to  the  corona  and  the  fore- 
skin rolled  back.    The  circular  line  of  incision  in  the  mucous  membrane 


210. — Anesthetization   of   Prepuce    in    Circumcision.     (After   Reclus.     "The 
American  Practice  of  Surgery,"  Vol.  IV.) 


is  now  infiltrated,  and  when  the  frenum  is  reached  it  is  given  a  special 
injection  of  a  few  drops  of  the  strong  solution.  The  mucous  membrane 
is  cut  away  and  the  sutures  inserted.  This  method  is  most  satisfactory 
and  absolutely  painless.    Krogius  applies  the  blocking  method  by  inject- 


FiG.  211. 


-Anesthetization  of  Base  of  Prepuce  in  Circumcision. 
"The  American  Practice  of  Surgery,"  Vol.  IV.) 


(After  Reclus. 


ing  subcutaneously  a  ring  about  the  base  of  the  penis,  while  Braun  in- 
jects 0.5  per  cent  novocain  about  the  coronary  sulcus. 

Eectum. — All  operations  about  the  anus  which  do  not  require  dilata- 
tion of  the  sphincter  fall  readily  within  the  domain  of  local  anesthesia, 
and  with  proper  technique  those  requiring  dilatation  may  nearly  all  be 
included.    As  to  the  anesthetic,  many  specialists  in  this  line  recommend 


LOCAL    ANESTHESIA 


515 


nothing  more  than  sterile  water  or  salt  solution,  while  Hertzlcr  ^  and 
others  are  enthusiastic  in  their  claims  for  quinin  and  urea  hydrochlorid 
on  account  of  the  abolition  of  post-operative  pain,  the  anesthesia  lasting 
sometimes  for  several  days.  I  have  had  no  experience  with  quinin  in 
this  region,  but  have  found  the  ordinary  cocain  solutions  very  satisfac- 
tory. The  anal  margin  is  particularly  sensitive,  and  it  is  well  in  attack- 
ing it  for  any  operative  procedure  to  begin  the  skin  injection  at  some 
little  distance  in  less  sen- 
sitive skin  and  gradually 
work  up  to  the  anus  by 
injecting  ahead  of  the 
needle.  In  this  way  ex- 
ternal hemorrhoids  and 
superficial  fistulas  may  be 
painlessly  excised,  and 
even  the  extensive  opera- 
tion of  Ball  for  pruritus 
offers  no  difficulty. 

The  whole  anal  re- 
gion and  lower  part  of 
the  rectum  can  be  anes- 
thetized by  a  circum- 
scribing injection,  so  that 
the  sphincter  may  be 
painlessly  and  thorough- 
ly dilated  for  the  ex- 
cision or  cauterization  of 
hemorrhoids,  the  excision 
of  fissures,  etc.    The  skin 

is  anesthetized  about  the  anus,  and  through  it  at  four  cardinal  points 
one  or  two  centimeters  from  the  anus  a  long  needle  is  introduced  and 
the  weak  solution  injected.  With  a  finger  in  the  rectum  as  a  guide, 
the  needle  is  thrust  into  the  substance  of  the  sphincter  and  along  the 
bowel  close  to  the  mucous  membrane,  injecting  always  ahead  of  it.  In 
this  way  the  sphincter  is  thoroughly  infiltrated  and  the  lower  part  of 
the  bowel  encircled  by  a  wall  of  anesthetizing  fluid.  In  a  few  minutes 
dilatation  may  be  slowly  proceeded  with.  I  have  several  times  in  very 
'poor  subjects  been  able  to  complete  such  an  extensive  procedure  as  the 
modified  Whitehead  operation  for  the  complete  excision  of  the  hemor- 
rhoidal area.  The  rectum  is  sensitive  only  in  its  lower  few  inches,  so  that 
for  the  treatment  of  the  valves  or  high  ulcers  and  polyps  no  further 
anesthetization  is  required.  For  extensive  dissection  in  the  ischio-rectal 
region  and  in  malignant  conditions  the  local  methods  are  not  advised. 
^Hertzler:     Am.  J.  of  Surg.,  1911,  M,  351, 


Fig.  212. — Showing  Separate  Injection  of  Fk^num 
IN  Circumcision.  (After  Reclus.  "  The  American 
Practice  of  Surgery,"  Vol.  IV.) 


516 


ANESTHESIA 


Gynecology. — Local  anesthesia  has  not  been  popular  in  gynecologic 
work,  nevertheless  its  possibilities  are  great,  and  reports  of  extensive 
operations  have  been  made.  Most  of  the  classical  perineal  operations 
might  be  done  under  infiltration.  Henrich  ^  reports  favorable  experi- 
ences in  dilating  and  operating  upon  the  cervix  after  thoroughly  inject- 
ing its  substance.  Sellheim^  describes  a  considerable  experience  in 
blocking  the  pudic  nerve  for  the  suture  of  perineal  tears,  application  of 

forceps,  and  various  gynecologic  oper- 
ations. Euge  ^  cites  numerous  vag- 
inal operations  and  two  complete 
vaginal  hysterectomies  accomplished 
j)ainlessly  under  a  simple  infiltration 
with  novocain.  Ivraatz  *  gives  an 
account  of  13  cases  in  which  he  did 
the  Alexander-Adams  operation  un- 
der local  anesthesia.  Sampson,^  and 
Broese  ^  have  also  reported  major 
gynecologic  work  under  local  meth- 
ods, and  Smith  and  Schwarz  "^  de- 
scribe two  cases  of  Csesarean  section 
painlessly  and  successfully  accom- 
plished under  infiltration  with  novo- 
cain. All  of  these  surgeons  support 
Lennander's  views  as  to  the  lack  of 
sensation  in  the  pelvic  viscera  them- 
selves and  emphasize  the  importance 
of  avoiding  traction. 

Abdomen. — In  operations  involv- 
ing only  the  abdominal  parietes 
without  invasion  of  the  peritoneal  cavity,  little  need  be  said,  as  the  ordi- 
nary technique  of  the  infiltration  method  applies.  All  the  usual  incisions 
for  intraperitoneal  work  are  conducted  in  this  way  until  the  peritoneum 
is  reached,  when  new  principles  enter,  viz.:  the  difference  in  the  sensi- 
tiveness of  the  parietal  and  visceral  peritoneum  and  the  sensibility  of  the 
abdominal  viscera  themselves.^ 


^3 


Fig.  213. — -Anesthetization  op  Anal 
AND  Rectal  Regions.  The  four 
dots  represent  the  injection  points. 
(After  Braun.  "The  American 
Practice  of  Surgery,"  Vol.  IV.) 


'Henrich:     Zentralh.  f.  Gyn.,  1909,  S3,  505. 

^'Sellheim:     Zentralh.  f.  Gyn.,  1910,  34,  897. 

^'Euge:     Zentralh.  f.  Gyn.,  1912,  36,  561. 

*Kraatz:     Zentralh.  f.  Gyn.,  1910,  34,  1129. 

■^Sampson:     Ann.  of  Surg.,  1905,  41,  216. 

"Broese:     Zentralh.  f.  Gyn.,  1910,  34,  1523. 

^  Smith  and  Schwarz :     Surg.  Gynec.  and  Ohstet.,  1910,  11,  423. 

^For  a  discussion  of  this  question  see  Mitchell:  /.  Am.  Med.  Assn.,  1911, 
57,  709,  where  a  review  of  the  subject  is  given  with  reference  to  the  views  of 
physiologists  and  surgeons. 


LOCAL    ANESTHESIA 


il7 


We  owe  to  Lennaiider  ^  the  (Jctermiiiatioii  oi'  the  following  facts, 
which,  though  disputed  in  part  by  physiologists  and  psychologists,  still 
form  the  best  working  basis  for  the  guidance  of  the  surgeon  in  intra- 
abdominal work  under  local  anesthesia.  The  parietal  peritoneum  is  in- 
tensely sensitive  to  pain,  but  not  to  pressure,  heat,  or  cold.  The  ab- 
dominal viscera,  on  the  other  hand,  possess  no  sense  of  pain.  In  other 
words,  the  visceral  peritoneum  and  the  abdominal  organs,  innervated 
only  by  the  vagus  or  sympathetic  nerves,  are  not  sensitive  to  pain,  and 


Fig.  214. — Sagittal  Section  of  Rectum,  Showing  the  Direction  of  the  Needle  in 
Anesthetizing  the  Rectum.  A,  cross-section,  in  a  vertical  plane,  of  the  anus  and 
rectum;  in  diagram  B  are  shown  the  four  points  (1,  2,  3,  4)  where  the  needle  should 
be  inserted.      (After  Braun.     "The  American  Practice  of  Surgery,"  Vol.  IV.) 


painful  abdominal  sensations  are  transmitted  only  by  the  phrenic,  the 
lower  six  intercostals,  and  the  lumbar  and  sacral  nerves,  which  supply 
the  parietal  peritoneum.  For  the  mesentery,  his  findings  are  not  abso- 
lute, though  he  considers  it  also  insensitive. 

ISTo  one  should  invade  the  abdomen  without  having  in  mind  these 
points.  It  can  be  readily  seen  that  an  especially  careful  technique  is 
necessary  and  that  the  parietal  peritoneum  is  to  be  treated  with  the 
greatest  respect.  Before  incising  the  parietal  peritoneum,  it,  or  its  sub- 
serous connective  tissue,  should  be  widely  infiltrated  to  allow  retraction, 
and  dragging  on  it  should  as  far  as  possible  be  avoided.  The  placing  of 
retractors  and  the  force  with  which  they  are  drawn  upon  should  be  care- 
fully regulated.  In  introducing  or  removing  gauze  pads,  care  should  be 
taken  iiot  to  rub  them  over  unanesthetized  parietal  peritoneum.  By  de- 
pressing the  viscera  in  introducing  the  pads,  and  then  allowing  them 
to  come  up  against  the  parietes,  they  may  be  painlessly  placed.    In  Jian- 

^Lennander:  Centralbl.  f.  Chir.,  1901,  8;  also  Mitt.  a.  d.  Grensgeb.  d.  Med. 
u.  Chir.,  1902,  10,  38;  1906,  15,  465;  1906,  16,  19;  1906,  16,  24;  see,  also,  "Tr- 
Seet.  on  Surg.,"  J.  Am.  Med.  Assn.,  1907,  211. 


518  ANESTHESIA 

dling  the  viscera,  avoid  dragging  on  the  mesenteries  or  parietal  attach- 
ments. Incising,  suturing,  burning,  or  crushing  any  part  of  the  gastro- 
intestinal tract  does  not  cause  pain  so  long  as  there  is  no  dragging  on 
the  parietal  peritoneum  directly  or  through  the  mesentery. 

It  is  evident,  then,  that  in  organs  lying  in  apposition  to  the  anterior 
abdominal  wall  operations  under  local  anesthesia  offer  little  difficulty. 
The  liver  may  be  painlessly  incised  with  knife  or  cautery  and  the  gall- 
bladder opened  for  the  removal  of  stones  or  for  drainage.  The  region  of 
the  common  duct,  however,  is  most  sensitive  and  difficult  of  approach. 
Gastrostomy  is  practically  always  possible,  and  gastro-enterostomy,  in  the 
absence  of  adhesions,  is  not  difficult.  Adhesions  between  viscera  can  be 
painlessly  separated,  while  the  separation  of  organs  adherent  to  the 
parietal  peritoneum  is  very  painful.  The  intestines  are  available  for 
suture,  anastomoses,  resections,  etc.  In  suspected  perforation  of  the 
intestine  in  typhoid  fever,  an  exploratory  laparotomy  under  local  anes- 
thesia is  acomplished  with  no  risk,  and  should  always  be  done  rather  than 
subject  the  patient  to  the  dangers  of  delay  while  awaiting  a  definite  diag- 
nosis. Typhoid  patients  make  ideal  subjects  as  a  rule,  and  the  whole 
operation,  including  suture  of  the  perforation,  can  ordinarily  be  com- 
pleted without  any  further  anesthetic.  The  appendix  in  interval  cases, 
when  free,  can  be  readily  removed,  as  we  have  demonstrated  in  many 
cases.  The  only  pain  experienced  is  in  clamping  or  pulling  on  its  mesen- 
tery, when  it  is  referred  to  the  region  of  the  umbilicus.  I  have  been 
able  also  by  very  careful  technique  to  remove  some  acutely  inflamed 
appendices  and  even  drain  deeply  situated  abscesses  after  packing  off  the 
rest  of  the  abdomen.  Inflammation  does  not  alter  the  sensitiveness  of 
the  viscera  to  operative  procedures,  but  greatly  increases  that  of  the 
parietal  peritoneum.  In  abdominal  surgery  the  combination  of  local  and 
general  anesthesia  is  often  a  most  valuable  one.  A  little  nitrous  oxid 
may  be  given  while  those  procedures  involving  the  parietal  peritoneum 
or  necessitating  mesenteric  traction  are  carried  out  and  the  rest  of  the 
operation  done  under  local  anesthesia. 

We  have  found  this  especially  useful  for  various  anastomoses  for  the 
relief  of  ineradicable  malignant  disease  in  greatly  exhausted  patients. 
In  gastro-enterostomy  for  such  a  condition  of  the  pylorus,  the  explora- 
tion and  demonstration  of  the  condition  are  made  under  local  anes- 
thesia. Whiffs  of  nitrous  oxid  are  given  while  the  anastomosis  clamps 
are  applied  and  the  stomach  and  intestines  brought  into  position  for 
suture.  The  suture  itself  is  painless,  and  the  local  anesthesia  induced 
for  the  incision  is  sufficient  for  the  closure  of  the  abdomen.  Lennander's 
article  is  replete  with  brilliant  abdominal  work  under  local  anesthesia, 
and  Schley  ^  cites  some  interesting  cases,  showing  what  extensive  opera- 
tions may  be  done  in  this  way.  Laewen's  method  of  paravertebral  nerve- 
1  Schley:     Med.  Bee,  Dec.  19,  1908. 


LOCAL    ANESTHESIA  519 

blocking,  reaching  the  nerves  just  after  their  exit,  has  been  applied  by 
Finsterer  ^  to  abdominal  work,  and  Kappis  ^  by  the  same  method  has 
several  times  removed  the  kidney.  Kappis  found  that  absolute  anes- 
thesia could  thus  be  obtained  for  operations  on  the  gall-bladder  and 
stomach,  thus  supporting  Lennander's  view  that  the  vagus  is  not  con- 
cerned in  the  sensory  innervation  of  this  region. 

Hernia  in  all  its  external  forms  belongs  by  choice  to  local  anesthesia. 
When  strangulation  is  present  local  anesthesia  is  imperative,  for  the  ques- 
tion of  hurry  is  eliminated,  as  well  as  the  shock  of  general  narcosis  and 
the  danger  of  drowning  from  fecal  vomitus.  Local  anesthesia  is  the  rule 
in  our  clinic.  It  is  usually  demanded  by  patients,  and  the  knowledge  of 
the  method  is  passed  on  from  one  to  another.  For  anatomical  reasons 
simple  inguinal  hernias  are  best  adapted  to  the  method,  but  femoral  and 
umbilical  are  easily  maneuvered.  Eecurrent  hernias  are  often  difficult, 
but  with  experience  comes  ease  in  their  management.  Age  is  no  bar  ex- 
cept for  early  childhood,  my  youngest  case  being  a  boy  of  ten.  I  have 
recently  had  a  successful  and  painless  operation  with  uneventful  recov- 
er}'  and  cure  in  a  man  of  96  with  a  strangulated  inguinal  hernia.  The 
greatest  obstacles  are  fat  and  adhesions,  because  of  technical  difficulties  in 
the  first  instance  and  pain  in  the  latter.  As  to  the  thoroughness  of  the 
operation,  there  is  no  necessity  for  the  altering  of  any  step  under  the 
local  method,  and  any  particular  type  of  operation  can  be  utilized.  The 
post-operative  period  is  much  more  comfortable,  from  the  absence  of 
nausea  and  vomiting.  Healing  is  if  anything  better.  Nerves  are  re- 
spected, thus  leaving  stronger  muscles,  and  recurrences  are  no  more  fre- 
quent. Why,  then,  should  a  patient  be  subjected  to  the  added  risk  and 
discomfort  of  an  unnecessary  general  anesthesia  ?  The  only  reason  could 
be  to  save  time  and  trouble  for  the  surgeon. 

Inguinal  Hernia. — The  radical  cure  of  inguinal  hernia  as  described 
by  Gushing  ^  is  one  of  the  most  practical  demonstrations  of  the  neuro- 
regional  method.  With  some  slight  modifications  we  use  this  in  all  in- 
guinal hernias.  The  skin  in  the  line  of  proposed  incision  is  infiltrated 
with  cocain  (1:1000)  or  novocain  (0.5  per  cent)  and  adrenalin,  pro- 
ducing a  wheal.  Through  this  an  injection  of  the  same  solution  is  made 
along  its  whole  length  into  the  subcutaneous  tissues.  Gentle  massage  is 
administered  over  this  injected  region  for  a  few  minutes — usually  while 
the  operator  is  putting  on  his  gown  and  the  towels  are  being  arranged. 
The  incision  at  its  upper  angle  is  carried  through  skin  and  subcutaneous 
tissue  to  the  aponeurosis  of  the  external  oblique.  If  the  incision  is  com- 
pleted throughout  its  whole  length  at  this  period,  unanesthetized  nerve 
fibers  with  one  or  two  large  vessels  will  be  encountered  in  the  fat,  divi- 

» Finsterer:      Zentralbl.  f.  Chir.,   1912,   39,   601. 
2  Kappis:     Zentralbl.  f.  Chir.,  1912,  39,  249. 
'Gushing:     Ann.  of  Surg.,  1900,  31,  1. 


520 


ANESTHESIA 


sion  of  which  is  painful.  When  the  external  oblique  is  exposed,  the  line 
of  the  inguinal  canal  can  be  seen  as  a  thinned-out  area  or  weak  line, 
which  leads  to  the  external  ring.  An  incision  is  made  in  this  in  the  line 
of  the  fibers  of  the  external  oblique,  which  exposes  immediately  the  ilio- 
inguinal and  ilid-hypogastric  nerves.  Into  each  of  these,  at  as  high  a 
point  as  possible,  the  needle  is  thrust,  pointing  centrally,  and  a  few  drops 


'# 


/\MBrlor  Cutan's  o<  V2  D    f 


Lateral  Cutan's  0(12  D 


Fig.  215. — Relations  of  the  Inguino-Scrotal  Nerves  to  the  Hernia  Incision.  I, 
Iliohypogastric;  II,  ilio-inguinal ;  III,  genito-crural ;  IV,  genital  branch;  V,  crural 
branch.     (After  Gushing.     "The  American  Practice  of  Surgery,"  Vol.  IV.) 


of  one  per  cent  cocain  or  novocain  plus  adrenalin  injected.  From  this' 
point  on  we  usually  abandon  the  knife  for  blunt-pointed  dissecting  scis- 
sors. The  skin  incision  can  now  be  completed  as  desired,  with  no  dis- 
comfort. The  division  of  the  external  oblique  is  completed  according  to 
the  operator's  method.  We  carry  it  directly  through  the  external  ring. 
The  flaps  of  external  oblique  are  cleared  by  dissection  with  scissors  and 
retracted  by  clamps.  The  nerves  are  freed  and  held  aside  by  one  of  the 
clamps  on  the  edge  of  the  external  oblique  to  preserve  them  from  in- 
jury. The  cremaster  is  divided  in  the  same  line  and  retracted,  thus  ex- 
posing the  sac  and  cord.  An  injection  of  the  weak  solution  is  made 
about  the  exposed  front  and  sides  of  the  neck  of  the  sac ;  and  between  the 
elements  of  the  cord  a  few  drops  of  the  strong  solution  are  diffused.    In 


LOCAL    ANESTHESIA 


521 


Incision.  ^FVlt^hTntobn'^. 

J/ech  c/'sax;  coyeree/3y 
tncuftei-yibr&s  ' 

JLui  -  i-ngrccinxK/ -^ 


small  hernias  the  neck  of  the  sac  may  be  completely  injected  at  this 
point,  but  in  larger  ones  it  is  impossible  to  reach  the  deeper  part.  The 
sac  is  now  opened  in  front,  its  edges  held  apart  with  clamps,  and  the 
contents  inspected  and  reduced  or  excised  as  occasion  demands.  We 
have  frequently  excised  large  portions  of  omentum  or  removed  the  appen- 
dix, and  in  cases  of 
strangulation  have 
resected  the  intes- 
'  tine.  The  posterior 
line  of  the  neck  of 
the  sac  can  now  be 
seen  as  a  thickened 
white  band.  This 
is  injected  with  the 
weak  solution,  com- 
pleting the  injec- 
tion of  the  neck. 
The  injection  is 
carried  well  up 
above  the  neck  of 
the  sac.  The  sac  is 
now  divided  at  its 
neck,  the  neck  is 
freed  and  closed 
with  a  purse-string 
suture.  Traction  on 
the  neck  of  the  sac 
is  to  be  carefully 
avoided ;  for  being 
parietal  peritoneum 
it  is  exquisitely  sen- 
sitive, and  its  dis- 
turbance causes  not  only  pain,  but  often  nausea  and  vomiting.  The 
removal  of  the  lower  part  of  the  sac  after  this  division  is  not  painful.  The 
subsequent  steps  of  the  operation,  depending  on  the  surgeon's  choice  of 
method,  may  be  carried  out  as  under  general  narcosis,  once  the  sac  is  dis- 
posed of.  Bodine  ^  considers  the  ilio-inguinal  nerve  as  the  only  one  neces- 
sary to  inject.  Bier  2  and  Braun  ^  hold  that  injection  of  nerves  at  all  is 
superfluous  and  unnecessary,  and  prefer  to  make  an  injection  of  the  whole 
area  through  the  skin  and  to  wait  fifteen  minutes  or  more  to  obtain  anes- 
thesia by  diffusion  of  the  fluid  about  the  nerves  and  sac.    I  have  not  found 


Fig.  216. — Sketch  Showing  Usual  Situation  of  Nebves 
AS  Exposed  After  Division  and  Reflection  of  the 
Aponeurosis  of  External  Oblique  Muscle.  (After 
Gushing.     "The  American  System  of  Surgery,"  Vol.  IV.) 


^Bodine:     Med.  'Bee,  1905,  68,  No.  17. 

=•6161:     Archiv  f.  Tclin.  Chir.,  1909,  90,  349. 

^ Braun:     "Die  Lokalansesthesie, "  Leipzig,  1913. 


522 


ANESTHESIA 


this  method  as  satisfactory  as  that  of  Gushing.  The  injection  of  the  indi- 
vidual nerves  adds  little  trouble.  The  nerves  are  subject  to  variation  in 
their  course,  but  not  enough  to  materially  interfere,  and  can  usually  be 
located  with  little  difficulty.  Cushing's  sketch  sliows  their  usual  distribu- 
tion. An  advantage  in  Cushing's  method  is  that  the  operation  can  be  be- 
gun almost  immediately  after  the  skin  injection  is  completed. 

Recurrent  hernias  were  formerly  considered  as  necessitating  general 
narcosis.     For  the  past  few  years  we  have  been  doing  them  all  under 


Fig.  217. — Scheme  of  Injection  in  Lakc.i.  UMiiiLK  al  Hernia..  The  figures  indicate 
the  injection  points;  the  arrows  and  dotted  hnci  ^hov,  the  directions  of  the  needle,  and 
the  solid  Hnes  the  incision.  This  represents  a  characteristic  example  of  the  circum- 
scribing blocking  method  of  Braun.     ("The  American  Practice  of  Surgery,"  Vol.  IV.) 

local  anesthesia,  and  find  them  a  little  more  troublesome,  although,  in 
most  cases  the  method  of  the  original  operator  being  unknown,  the 
anatomical  relations  may  be  at  first  a  little  confused.  In  such  cases  it  is 
best  to  carry  the  incision  higher  and  block  the  nerves  well  above  the 
former  field  of  operation.  The  region  is  then  anesthetized,  and  the  dis- 
section of  scar  tissue  made  easy  and  painless. 

Femoral  hernias,  if  small,  can  be  readily  treated  by  simple  layer  in- 
filtration. In  larger  hernias,  or  where  strangulation  is  present,  the  in- 
cision is  carried  up  above  the  external  ring,  a  small  incision  made  in  the 
external  oblique,  and  the  ilio-inguinal  nerve  blocked  with  1  per  cent 
cocain.  With  the  anesthesia  produced  in  this  way  and  a  generous  infil- 
tration with  the  weak  solution  above  the  sac,  no  difficulty  is  experienced. 

Umbilical  hernias  can  practically  always  be  repaired  under  local 
anesthesia,  and  the  large  ones  in  very  fat  women  demand  it.  For  ordi- 
nary ones  the  circumscribing  injection  of  Braun  with  separate  injection 


LOCAL  ANESTHESIA  523 

of  tho  skin  is  satisfactory.  I  prefer  local  anesthesia  in  all  cases,  and 
use  the  layer  method  of  infiltration  with  the  overlapping  closure  of 
Mayo.  Even  the  largest  are  adapted  to  this  form  of  treatment.  Occur- 
ring as  they  do  in  very  fat  individuals — bad  risks  under  general  narcosis 
— they  make  a  striking  tribute  to  the  value  of  local  anesthesia.  I  did 
such  an  oi^eration  four  years  ago  on  a  woman  weighing  over  three  hun- 
dred pounds,  using  throughout  a  solution  of  1 :  2000  cocain  plus  adre- 
nalin. Two  skin  incisions  over  30  cm.  long,  including  between  them  a 
large  area  of  skin  and  fat  to  be  excised,  were  made  transversely.  The 
sac  was  opened  without  attempting  to  free  it  from  the  overlying  skin. 
It  was  filled  with  many  feet  of  adherent  large  and  small  intestine  and 
omentum.  The  neck  of  the  sac,  about  15  cm.  in  diameter,  was  thor- 
oughly infiltrated  with  the  cocain  solution.  The  contents  were  freed 
and  reduced.  The  sac  was  then  divided  near  its  neck,  and  after  being 
dissected  from  the  skin  was  removed.  The  opening  was  repaired  by  the 
Mayo  overlapping  method,  the  peritoneal  site  of  each  suture  being  in- 
jected with  cocain  before  introducing  the  needle.  Although  this  opera- 
tion consumed  over  three  hours,  the  patient  suffered  no  shock,  had  no 
nausea,  made  a  good  recovery,  and  has  remained  cured  of  this  condition. 
In  the  same  way  most  post-operative  ventral  hernias  can  be  handled 
under  local  anesthesia.  They  consume  a  great  deal  of  time,  and  are  a 
source  of  wear  and  tear  on  the  surgeon,  but  the  results  are  ample  re- 
ward. The  repair  of  hernias  is  one  of  the  most  satisfactory  applications 
of  local  anesthesia  if  the  surgeon  will  have  ever  in  mind  the  cardinal 
principles:  the  differences  in  the  sensation  of  tissues,  a  sufficient  and 
suitable  application  of  properly  prepared  anesthetizing  solution,  and, 
above  all,  patience  and  plenty  of  time. 

PAET    II 

INTEA VENOUS    ANESTHESIA 
William  F.  Honan,  M.  D.  and  J.  Wytxis  Hassler,  M.  D.  ^ 
Physiology. 
Technique. 

Mixed  Porms  of  Anesthesia. 
Blood  Changes. 
Urinary  Examination. 

General  anesthesia  by  the  intravenous  route  was  demonstrated  as  a 
possibility  by  Ore  of  Lyons  in  1872,  chloral  hydrate  in  solution  being  the 

1  Surgeons  to  the  Metropolitan  Hospital,  N.  Y.  City.  Abstract  from  a  paper 
read  before  The  American  Association  of  Anesthetists,  June,  1913;  published  in 
Ann.  of  Surg.,  Dec,  1913,  J.  B.  Lippincott  Co.,  N.  Y.  With  permission  of 
Dr.  Honan. 


524  ANESTHESIA 

hypnotic  agent  employed.  The  method  seemed  very  successful  in  51 
cases,  but  subsequent  fatalities,  due,  perhaps,  both  to  the  drug  used  and 
the  method  employed,  led  to  its  discontinuance. 

At  the  Berlin  Surgical  Congress,  in  1910,  six  surgeons  of  prominence 
corroborated  the  success  of  Burckhardt,  who  led  in  perfecting  the  tech- 
nique of  this  method.  Kiimmel  reported  90  cases  in  his  own  experi- 
ence. Later,  Fedorow,  of  St.  Petersburg,  collected  530  cases  from  three 
Eussian  clinics,  in  which  hedonal  was  used  with  no  deaths  attributable  to 
the  anesthetic.  Fedorow  and  his  colleagues  used  a  0.75  per  cent  solution 
of  hedonal  in  normal  saline  solution. 

Physiology. — The  correct  interpretation  by  the  anesthetist  of  the 
physiological  effect  is  that,  when  once  a  level  of  narcosis  sufficient  for  the 
purposes  of  the  surgeon  is  reached,  very  little  anesthetic  is  necessary  to 
maintain  the  anesthetic  tension,  and  that  so  long  as  the  tissues  are  not 
overnarcotized  the  cells  will  part  with  the  anesthetic  and  regain  their 
normal  physiological  status  when  the  administration  of  the  drug  is  with- 
drawn. 

In  the  employment  of  intravenous  anesthesia,  the  agent  is  directly 
introduced  into  the  blood,  and  is  maintained  there  at  the  desired  anes- 
thetic tension.  In  this  method,  the  production  of  anesthesia  is  very 
rapid,  the  preliminary  state  of  excitement  is  nearly  always  absent,  the 
patient  breathes  almost  naturally,  the  color  of  the  skin  remains  good, 
and  the  relaxation  and  flexibilty  of  the  muscles  are  absolutely  satisfac- 
tory to  the  operator.  The  degree  of  narcosis  can  be  maintained  to  a 
nicety,  and  at  the  completion  of  the  operation  the  patient  often  answers 
questions  rationally  before  leaving  the  operating  table. 

For  the  safe  and  satisfactory  induction  of  anesthesia  by  the  intra- 
venous route,  it  is  highly  essential  that  the  details  of  the  technique, 
which  is  remarkably  simple,  be  carefully  and  systematically  observed. 

Honan's  own  work  has  embraced  about  all  of  the  operations  usually 
employed  in  a  large  general  surgical  service,  males,  females,  and  children, 
and,  at  the  present  time,  we  can  recall  only  one  death  in  about  350  ad- 
ministrations that  could  be  justly  attributed  to  the  method  of  anesthe- 
sia, and  in  that  single  instance  the  regrettable  fatality  was  due  to  the 
unfortimate  misunderstanding  of  a  verbal  order  as  to  anodynes  after  the 
operation. 

Technique. — For  the  intravenous  use  of  ether,  the  patient,  having 
been  prepared  for  operation,  is  taken  to  the  anesthetizing  room  about 
thirty  minutes  before  the  time  for  operation,  and  placed  preferably  upon 
the  operating  table  which  is  to  be  used  during  the  operation.  A  sub- 
cutaneous injection  of  morphin  sulphate,  gr.  1/6;  atropin  sulphate,  gr. 
1/100;  and  scopolamin,  gr.  1/1000,  is  given  at  one  dose — ^preferably  in 
the  loose  tissues  of  the  chest,  abdomen,  or  thigh.  From  this  time  until 
the  actual  anesthesia  is  accomplished,  it  is  extremely  advisable  to  keep 


INTRAVENOUS  ANESTHESIA  525 

the  patient  as  quiet  as  possible,  so  that  when  the  administration  begins 
the  patient  is  in  a  condition  of  reposeful  relaxation  of  mind  and  body. 
No  matter  how  anxious  or  fearful  of  the  result  of  the  operation,  the  pa- 
tient in  thirty  minutes  is  sustained  and  supported  by  the  hypodermic 
medication,  and  the  injurious  effects  of  acute  fear,  which  Crile  has  dem- 
onstrated are  identical  with  those  of  acute  shock,  are  successfully  com- 
bated. A  five  to  seven  and  one-half  per  cent  solution  of  ether  with  fil- 
tered sterile  Einger's  solutioli  (normal  saline  solution  may  be  used  if  the 
other  is  not  available)  at  a  temperature  of  85°  F.  is  poured  into  a  reser- 
voir which  has  a  capacity  of  3000  c.c.  The  solution  is  thoroughly 
mixed,  and  care  should  be  taken  to  see  that  the  ether  is  dissolved;  for 
even  after  violent  succussion  there  may  be  some  stratification,  the  lighter 
ether  floating  upon  the  surface  of  the  solution. 

The  solution  having  been  prepared,  the  reservoir  is  adjusted  on  a 
stand  eight  feet  above  the  floor  level,  at  which  point  it  remains  during 
the  administration.     The  fluid  flows  through  an  indicator  which  con- 


FiG.  218. — Holder  for  Arm. 

tains  a  pipette,  then  through  a  rubber  tubing  into  a  blunt  cannula,  and 
so  into  the  vein.  The  indicator  consists  of  a  cylindrical  or  globular  bulb 
of  a  capacity  of  from  two  to  four  ounces  with  an  inside  pipette  very 
similar  to  that  used  in  the  Murphy  apparatus  for  protoclysis.  AAHien  the 
apparatus  is  working  properly,  the  lower  half  of  the  indicator  is  filled 
with  solution,  while  the  upper  half  contains  air.  The  solution  flows 
from  the  tank  through  the  pipette,  and  drops  on  the  surface  of  the  fluid 
in  the  lower  half  of  the  indicator.  By  means  of  a  compression  top,  placed 
below  the  indicator,  the  rate  of  flow  can  be  accurately  controlled,  and,  if 
the  fluid  in  the  bulb  is  kept  at  a  proper  level,  a  satisfactory  index  is  fur- 
nished as  to  the  rate  the  solution  enters  the  vein.  Usually  the  arm 
furthest  from  the  operator  is  selected  and  the  median  basilic  or  cephalic 
vein  exposed,  but  should  the  operative  field  be  the  skull,  face,  neck,  or 
chest,  where  the  infusion  apparatus  would  inconvenience  the  surgeon 


526  ANESTHESIA 

or  his  assistant,  the  internal  saphenous  at  the  internal  malleolus  is  se- 
lected. As  a  matter  of  fact,  any  vein,  in  ^py  locality  remote  from  the 
operator,  may  be  utilized,  the  simple  precaution  being  that  it  is  super- 
ficial, free,  from  varicosities,  and  sufficiently  large  to  be  readily  exposed 
and  to  admit  the  small  cannula  through  which  the  anesthetic  solution  is 
to  be  introduced  into  the  system.  If  the  elbow  is  selected,  a  padded 
splint,  large,  at  one  end  and  tapering  to  a  sij^e  somewhat  wider  than  the 
forearm,  is  placed  beneath  the  patient,  extending  from  beyond  the  tips 


Fig.  219. — Vein  Exposed  and  Ligated  Distally.     This  ligature  not  shown  in  illus- 
tration.    Vein  is  being  opened  with  scissors.      {Annals  of  Surgery.) 

of  the  fingers  to  the  opposite  side  of  the  body ;  a  few  turns  of  a  three- 
inch  rubber  bandage  just  above  the  wrist  will  maintain  extension  of  the 
forearm  and  prevent  involuntary  movements  which  might  occur  in  the 
first  stage  of  anesthesia  and  dislodge  the  cannula  from  the  vein,  an  em- 
barrassing but  easily  preventable  accident.  A  space  of  about  four  to  six 
inches  over  the  bend  of  the  elbow  is  now  firmly  wiped  once  over  with 
a  5  per  cent  solution  of  thymol  in  carbon  tetrachlorid  on  a  piece  of 
gauze.  This  is  sufficient  to  thoroughly  sterilize  the  skin,  which  has  not 
received  any  previous  preparation.  It  has  an  advantage  over  iodin,  which 
is  usually  employed,  in  that  it  is  more  efficacious  and,  as  an  antiseptic, 
does  not  discolor  the  skin,  a  great  advantage  when  superficial  veins  are 
to  be  dissected.  It  is  not  advisable  to  bandage  the  distal  extremity  of  a 
limb  to  render  the  veins  more  prominent,  as  the  compressor  must  be  very 
quickly  removed  when  the  cannula  is  introduced,  and  that  often  adds  to 


INTRAVENOUS  ANESTHESIA  527 

the  difficulty.  If  the  veins  are  not  particularly  prominent,  an  assistant 
may  make  some  pressure  with  the  hand  on  the  upper  and  inner  aspect 
of  the  arm  while  the  vein  is  being  exposed.  There  should  be  no  blunder- 
ing at  this  point,  since  nothing  so  disturbs  the  morale  of  the  patient,  de- 
stroys confidence,  and  adds  fear  and  anxiety,  when  composure  should  be 
supreme,  as  the  futile,  clumsy  attempts  to  find  the  vein  by  anesthetists 
not  accustomed  to  doing  surgical  work. 

We  make  it  very  emphatic  that  the  exposure  of  the  vein  and  the  in- 
troduction of  the  cannula  should  be  done  with  scrupulous  regard  to  asep- 
sis, since  septic  thrombosis  at  this  point  might  lead  to  unpleasant  after 


Fig.  220. — Cannula  Introduced  and  Tied  in  the  Vein.     {Annals  of  Surgery.) 

results.  The  skin  over  the  vein  selected  is  infiltrated  with  a  few  drops  of 
one-half  of  one  per  cent  solution  of  cocain,  sufficient  to  make  a  blot  one- 
half  inch  in  diameter.  The  skin  containing  the  blot  is  drawn  aside  from 
the  vein  with  the  thumb  of  the  left  hand  so  as  not  to  be  directly  over  the 
vein,  and  a  small  incision  one-third  to  one-half  an  inch  is  made  through 
into  subcutaneous  fat.  The  vein  is  now  exposed  by  wiping  with  a  bit  of 
gauze  for  two  or  three  firm  strokes.  A  small  hemostat,  with  a  double 
ligature  of  ISTo.  1  catgut,  is  now  carefully  thrust  beneath  the  vein,  and, 
by  gently  moving  it  horizontally  in  and  out,  the  vessel  is  lifted  from  its 
bed  and  the  exposure  is  complete.  The  ligature  is  cut,  the  lower  half  is 
tied  tightly  and  attached  to  a  hemostat,  the  upper  half  being  tied  loosely 
with  half  a  knot  and  also  clamped  with  a  hemostat.  *  The  operator  now 
takes  the  proximal  ligature  in  his  left  hand,  the  assistant  making  slight 
tension  on  the  one  distal;  the  vein  is  lifted  and  put  somewhat  on  the 
stretch.  With  a  small  rather  blunt  scissors  an  incision  is  made,  em- 
bracing about  two-thirds  the  caliber  of  the  vessel.     The  operator  now 


528 


ANESTHESIA 


takes  the  cannula  in  his  right  hand,  and,  slightly  relaxing  tension  on  the 
proximal  ligature  which  he  holds,  he  is  able  usually  to  quickly  insinuate 


Fig.  221a. 


Fig.  221b. 
Figs.  221a  and  b. — Salvarsan  Method  of  Introducing  the  Needle. 

it  into  the  cavity  of  the  vein.  By  manipulating  the  proximal  ligature  as 
to  tension,  he  is  able  to  facilitate  this  movement,  though  it  is  often  ad- 
visable to  have  the  assistant  pick  up  the  flap  of  the  incised  vein  with  a 


INTRAVENOUS  ANESTHESIA  529 

small  pair  of  anatomical  forceps  which  exposes  the  lumen,  steadies  the 
vessel,  and  very  considerably  facilitates  the  introduction  of  the  cannula. 
The  half  loose  knot  in  the  proximal  ligature  is  now  drawn  snugly  down 
on  the  cannula,  which  is  sufficient  to  hold  it  in  place.  A  piece  of  ad- 
hesive plaster  about  3  inches  wide  is  placed  about  the  rubber  tubing  con- 
nected with  the  cannula,  which  relieves  all  tension  and  tends  more  than 
anything  else  to  prevent  the  accidental  slipping  of  the  tube  from  the 
vein.  A  large  gauze  pack  is  now  placed  over  the  incision,  and  the  sur- 
geon and  assistant  take  their  respective  places  to  begin  the  contemplated 
operation.  We  have  found  that  actual  exposure  of  the  vein  and  tying  on 
of  the  cannula  is  the  most  satisfactory  and  safe  procedure,  many  sugges- 
tions having  been  made  as  to  the  use  of  a  technique  similar  to  that  em- 
ployed in  the  salvarsan  treatment;  special  needles  have  been  made  and 
tried  only  to  return  to  the  very  satisfactory  procedure  described  above. 

The  solution  should  be  administered  at  a  full  flow  at  the  beginning, 
the  anesthetist  reducing  the  stream  at  the  appearance  of  the  usual  signs 
of  surgical  anesthesia.  It  is  quite  as  incumbent  upon  the  anesthetist  to 
taJce  the  usual  precautions  to  secure  and  m-aintain  an  unobstructed  air- 
way and  ejficient  respiratory  act,  as  in  the  usual  method  of  anesthesia. 
Ether  is  rapidly  eliminated  by  the  lungs  in  this  method,  and,  as  is  true 
of  all  methods,  efficient  respiration  prevents  accumulation  and  tension 
on  the  tissues,  increases  its  output,  and  lessens  its  toxicity.  In  from  one 
to  five  minutes  anesthesia  will  be  complete,  and  the  operation  may  pro- 
ceed. 

It  is  highly  important,  as  was  noted  above,  to  be  economical  in  the 
use  of  the  anesthetic  solution ;  the  patient  should  be  placed  in  the  appro- 
priate position  for  the  intended  operation,  the  operative  field  draped, 
the  skin  disinfection  completed,  and  the  surgeon  absolutely  ready  to  make 
the  initial  incision  when  the  cannula  is  inserted  into  the  vein.  There  is 
a  limit  to  the  patient's  tolerance  for  even  salt  solution,  and  it  is  very 
desirable  that  any  portion  of  the  period  of  anesthesia  be  not  wasted  upon 
preparation,  but  reserved  solely  for  the  actual  operative  technique.  When 
the  degree  of  narcosis  is  obtained,  which  varies  somewhat  with  the  nature 
of  the  operation,  the  flow  into  the  vein  is  reduced  by  the  control  cock 
just  below  the  indicator.  It  may  be  allowed  to  drip  in  a  very  fine  stream 
or  at  the  rate  of  40  to  60  drops  per  minute,  the  corneal  reflex  affording  a 
reliable  guide  for  administration.  The  anesthetist  readily  becomes  ac- 
quainted with  the  effects  of  the  drug  by  this  method,  and,  as  narcosis 
can  be  absolutely  and  beautifully  controlled,  there  is  no  need  for  any 
embarrassment  to  the  operator  from  involuntary  muscular  contractions. 
Again,  let  it  be  urged  that  careful  attention  be  directed  to  the  main- 
tenance of  an  open  airway,  and,  as  the  muscles  of  the  jaws  and  neck  are 
very  much  relaxed,  the  tongue  should  not  be  allowed  to  drop  back  into 
the  pharynx.     It  is  more  important  to  attend  to  these  respiratory  pre- 


530 


ANESTHESIA 


cautions  than  if  the  patient  were  being  anesthetized  by  the  inhalation 
method.  The  Hewitt  breathing  tube  is  very  useful  in  assisting  to  main- 
tain a  proper  airway  and  also  as  an  aid  to  holding  the  tongue  forward. 
Our  usual,  practice  is  to  fix  the  tongue  with  a  pair  of  fine  tenaculum  for- 
ceps and  let  them  hang  by  their  own  weight.  We  advocate  a  continuous 
flow  in  intravenous  anesthesia,  no  matter  what  agent  is  employed  as  the 
hypnotic,  though  a  few  times  we  have  interrupted  the  stream  for  a  few 


Fig.  222. — Patient  under  Anesthesia  by  the  Intravenous  Method.     Note  globular 
indicator  with  control  stopcock;  also  method  of  maintaining  arm  in  proper  position. 


moments  without  any  appreciably  harmful  effect  at  the  conclusion  of  the 
operation,  unless  it  has  been  quite  prolonged;  particularly  if  ether  alone 
has  been  used,  the  dressings  should  be  applied  before  the  flow  is  actually 
stopped,  as  the  return  to  consciousness  often  comes  very  promptly  and 
the  patient  may  resist  efforts  to  flnish  the  toilet  of  the  incision  properly. 
The  blood  pressure  rises  slightly  with  the  use  of  ether  in  this  way.  We 
use  it  preferably  in  the  old  and  cachectic  patients,  avoiding  its  use  in 
young,  full-blooded,  or  alcoholic  subjects. 

Oozing  is  more  noticeable,  perhaps,  in  the  operative  field,  and,  if  the 
cavity  of  the  abdomen  is  the  seat  of  the  operation,  fluid  quickly  accumu- 


INTRAVENOUS   ANESTHESIA 


531 


lates  there.  If  extensive  adhesions  are  to  be  dealt  with,  the  fluid  rap- 
idly becomes  blood-stained,  and  there  might  be  instances  where  this 
might  embarrass  and  delay  the  operator,  but  we  have  not  been  so  trou- 
bled. The  patient  may  be 
brought  from  one  degree  of 
anesthesia  to  another  very 
rapidly  by  the  judicious  use  of 
the  control  indicator,  and  it  is 
well  that  the  operation  be  en- 
tirely finished  and  dressings 
applied  before  the  administra- 
tion is  stopped.  If  the  admin- 
istration has  been  skillfully 
performed,  the  patient  will 
quietly  drop  to  sleep  without 
any  appreciable  indication  of 
a  stage  of  excitement.  The 
face  will  flush,  eyes  roll,  and 
some  of  the  voluntary  muscles 
stiffen  for  perhaps  a  few  sec- 
onds, when  suddenly  the  pa- 
tient seems  to  have  fallen  into 
a  quiet  but  deep  sleep  without 
the  noisy  stertorous  respiration 
usually  associated  with  nar- 
cosis. The  usual  signs,  corneal 
reflex,  pupillary  indication, 
etc.,  are  about  as  noted  in  the 
same  degree  of  anesthesia  by 
the  inhalation  method.  At  the 
conclusion  of  the  operation, 
which  may  last  from  two  to 
three  hours,  at  the  expenditure 
of  about  1000  c.  c.  of  solution 
per  hour,  the  cannula  is  with- 
drawn by  a  quick  jerk  from 
the  vein,  the  loose  half  knot  of 
catgut  is  tied,  which  ligates 
the  proximal  portion  of  the 
Yein.  The  wound  is  closed  with  a  few  fine  silk  sutures  of  000  silk  on 
No.  10  straight  needles,  wiped  once  with  carbon  tetrachlorid  and 
thymol,  50  per  cent  solution,  and  an  aseptic  dressing  applied.  The 
patient  is  returned  to  bed,  and,  if  much  solution  has  been  used  and 
tJlP  operation  prolonged,  a  semi-Fowler  position  is  employed,  and  the 


Fig.  223. — Another  Model  Apparatus  for 
Intravenous  Anesthesia.  The  reservoir 
and  tube  for  preliminary  narcosis  are  in  one 
piece,  and  the  solutions  are  controlled  by 
an  ingeniously  perforated  glass  stopcock. 
(Annals  of  Surgery.) 


532  ANESTHESIA 

nurse  instructed  to  turn  the  patient  every  one  or  two  hours.  This  is 
a  necessary  precaution;  for,  if  a  very  great  quantity  of  fluid  is  used, 
there  are  naturally  some  possibilities  of  pulmonary  edema,  and 
curiously  enough,  certain  spots  on  the  back  and  buttocks  often 
develop,  looking  like  bruises.  This  is  due  to  the  anesthetic  fluid 
settling  in  the  loose  fatty  tissue  of  the  most  dependent  portion  of 
the  body.  Occasionally  the  patient  will  have  a  chill  such  as  may  occur 
when  saline  infusion  is  given  to  combat  shock.  This  condition  quickly 
subsides,  particularly  if  hot-water  bags  are  placed  about  the  patient.  It 
is  a  curious  fact  that  this  phenomenon  will  occur  when  solutions  ten  de- 
grees higher  than  the  body  temperature  are  introduced  into  the  circu- 
lation. The  employment  of  ether  in  this  way  seems  almost  devoid  of 
danger  from  either  immediate  or  remote  complications,  and  represents 
the  basic  type  of  intravenous  anesthesia,  from  which  have  grown  many 
modifications. 

Mixed  Forms  of  Anesthesia. — Experience  has  shown  that  in  intra- 
venous anesthesia  better  results  are  obtained,  both  as  to  the  production 
of  the  narcosis  and  a  state  of  anoci-association,  if  hypnotic  agents  are  em- 
ployed at  the  same  time,  which  are  of  very  widely  different  character, 
both  as  to  chemistry  and  physiological  action  and  which  may  be  said  to 
act  synergetically.  If  the  narcosis  is  first  established  by  the  use  of  a 
hypnotic,  like  hedonal  or  isopral,  and  the  subsequent  course  conducted 
with  the  ether  solution,  the  anesthesia  is  more  satisfactory  in  every  way. 
The  method  seems  safer  and  more  efficient;  less  solution  is  required  to 
maintain  the  narcosis  and  the  post-anesthetic  history  is  free  from  inci- 
dents. Of  the  many  substances  employed  in  the  preliminary  narcosis, 
isopral  seems  to  best  fulfill  the  requirements.  Into  the  smaller  reservoir 
is  placed  250  c.  c.  of  a  one  and  one-half  per  cent  solution  of  isopral  in 
Ringer's  solution,  which  has  been  boiled,  filtered,  and  maintained  at  a 
temperature,  approximately,  of  85°  F.j  into  the  larger,  2,000  c.  c.  of  a 
five  per  cent  solution  of  ether.  Artery  clips  or  compression  tops  are 
placed  on  the  tubes  leading  from  each  reservoir  to  control  the  outlets.  The 
apparatus,  particularly  rubber  connections,  is  now  carefully  examined  to 
see  that  all  parts  are  secure,  since  the  slipping  of  a  rubber  tube  from  its 
glass  connection  during  anesthesia  makes  a  very  embarrassing  situation, 
which  may  be  easily  prevented  by  a  careful  inspection  before  the  ap- 
paratus is  used.  Everything  being  in  readiness  now,  the  vein  examined, 
the  solution  from  the  smaller  reservoir,  which  will  be  used  first,  is  al- 
lowed to  flow  through  the  tubing  to  force  out  the  air  and  to  fill  the  in- 
dicator a  trifle  below  the  free  end  of  the  pipette.  The  cannula  being 
introduced  into  the  vein,  the  isopral  solution  is  allowed  to  flow  slowly  into 
the  vein,  allowing  four  to  five  minutes  for  the  entire  250  c.c.  to  enter  the 
circulation.  Usually,  before  that  amount  has  been  used,  the  patient  has 
passed  from  a  condition  of  consciousness  to  what  is  apparently  a  normal 


INTRAVENOUS   ANESTHESIA  533 

sleep,  without  a  stage  of  excitement,  and,  if  this  preliminary  narcosis  has 
been  skillfully  conducted,  there  is  nothing  in  tlie  entire  realm  of  anes- 
thesia which  so  approximates  normal  sleep.  The  patient  breathes  quietly 
and  naturally,  there  is  no  noisy  respiration,  the  color  remains  good,  and 
the  transition  from  wakefulness  to  deep  sleep  has  l)een  so  quietly  accom- 
plished that  one  is  scarcely  prepared  to  believe  that  narcosis  is  complete 
until  examination  shows  complete  muscular  relaxation  and  absence  of 
corneal  reflex.  This  stage  may  be  reached  before  the  entire  250  c.c.  of 
isopral  solution  has  been  used ;  often  100  c.c.  is  sufficient.  However,  in 
the  very  robust,  and  particularly  in  those  addicted  to  the  use  of  drugs  or 
alcohol,  this  preliminary  stage  may  be  prolonged.  Before  the  isopral 
solution  is  entirely  exhausted,  the  clip  is  placed  upon  the  tubing  leading 
from  the  smaller  reservoir  and,  simultaneously,  the  one  from  the  larger 
reservoir  is  removed,  allowing  the  ether  solution  to  enter  the  circulation. 
Narcosis  having  been  wholly  or  partially  accomplished,  the  flow  in  this 
instance  is  just  sufficient  to  maintain  the  degree  already  established,  or 
such  as  may  meet  the  demands  of  the  operation.  Hedonal  may  be  used 
in  the  same  way  except  that  it  is  used  in  a  0.75  per  cent  solution.  It  is 
a  more  powerful  respiratory  sedative  than  isopral,  and  the  precaution 
should  be  observed  that  it  should  enter  the  circulation  slowly  and  espe- 
cial attention  be  paid  to  its  proper  elimination  by  the  maintenance  of  an 
adequate  airway.  It  is  possible  to  deeply  narcotize  a  patient  with 
hedonal  in  ten  seconds  after  the  cannula  is  introduced  into  the  vein  by 
allowing  the  flow  full  headway,  but  such  effects  are  sensational  in  their 
rapidity,  serve  no  useful  purpose,  and  are  not  always  devoid  of  danger. 

Blood  Changes. — In  every  case  it  was  found  that  ether  raised  the 
blood  pressure  from  2  to  24  mm.,  this  rise  being  followed  by  a  fall  of  2  to 
20  mm.  in  from  one  to  three  hours  and  then  gradually  returned  approxi- 
mately to  the  j)oint  observed  before  operation. 

Hedonal  invariably  lowered  the  blood  pressure  from  6  to  25  mm.  of 
mercury,  paraldehyd  in  about  the  same  proportion,  so  also  isopral.  When 
mixtures  were  used,  such  as  hedonal  and  ether,  paraldehyd,  or  isopral  and 
ether,  the  blood  pressure  was  influenced  to  the  extent  of  being  about 
the  same  as  before  the  operation,  as  only  a  small  quantity  of  the  hyp- 
notics was  used  in  the  anesthetic  mixtures.  They,  however,  in  every  in- 
stance prevented  the  increased  pressure  noted  when  ether-scopolamin- 
morphin  combination  was  used.  It  was  singularly  noted  that  female  pa- 
tients showed  little  or  no  changes  in  the  blood  pictures,  neither  did  males 
in  operations  of  short  duration.  Alcoholic  habitues  naturally  required 
more  anesthetic  and,  in  one  case,  in  which  anesthesia  was  accomplished 
with  a  five  per  cent  solution  of  paraldehyd  in  normal  saline,  there  was 
decided  crenation  of  red  cells  with  some  clumping  crenation,  and  some 
crenation  was  noted  when  a  mixture  of  ether  3  per  cent  and  paraldehyd 
25  per  cent  was  employed.    Some  crenation  was  also  noticed  in  one  case 


534  ANESTHESIA 

where  a  large  quantity  (3,500  c.c.)  of  7  per  cent  ether  in  normal  saline 
was  used.  In  every  case  the  blood  picture  returned  to  normal  in  about 
four  hours. 

Hemoglobin^  estimated  by  Tallquist  scale,  showed  an  average  diminu- 
tion of  5  per  cent.  There  seemed  to  be  no  changes  either  in  appearance 
or  number  of  the  leucocytes,  and  where  an  actual  leucocytosis  was  ob- 
served before  the  infusion  was  given  the  blood  picture  was  practically  un- 
changed. The  erythrocytes  were  not  materially  affected,  except  in  three 
cases  in  which  narcosis  had  been  produced  by  paraldehyd. 

Urinary  Examination. — The  urinary  analyses  made  before  the  opera- 
tion and  for  three  or  four  days  afterward  showed  no  marked  differences 
in  the  specimens.  The  total  amount  was  increased  and  specific  gravity 
lowered  during  the  first  twenty-four  hours ;  often  the  specific  gravity  and 
solid  content  of  the  urine  remained  unchanged.  In  no  case,  even  after 
employing  7.5  per  cent  ether  solution,  did  blood,  albumin  or  easts  appear 
in  the  urine,  though  German  observers  have  reported  occasional  cases  of 
transient  hemoglobinuria  after  the  use  of  the  stronger  ether  mixtures. 
It  was  quite  surprising  that  there  was  not  a  large  urinary  output  after 
the  infusion  of  large  quantities  of  fluid,  so  much  so  that  the  patients 
were  regularly  catheterized,  thinking  perhaps  there  might  be  some  vesical 
paresis  from  overdistention,  but  we  failed  to  find  at  any  time  a  urinary 
output  in  proportion  to  the  amount  of  fluid  introduced  into  the  circula- 
tion. 


CHAPTER    XIV 

LOCAL   ANESTHESIA    AS    APPLIED    IN    DENTISTEY 

Herrmann  Prinz,  M.D.^  D.D.S. 

History. 

The  Hypodermic  Method. 

Cold. 

Mode  of  Application  of  Ethyl  Chlorid. 

CocAiN :  Preparation  of  Cocain  Solutions ;  Sterilization  of  Solu- 
tions; Substitutes  Proposed  for  Cocain;  The  Hypodermic  Armamen- 
tarium. 

Teci-inique  of  Injection  :  The  Subperiosteal  Injection ;  Peridental 
Anesthesia;  Intra-osseus  Injection;  Perineural  Injection;  The  Injection 
Into  the  Pulp;  Methods  of  Anesthetizing  the  Pulp. 

History. — Probably  the  oldest  known  dental  prescription  that  was 
used  for  the  purpose  of  abolishing  pain  arising  from  an  aching  tooth  is 
recorded  upon  a  clay  tablet  that  was  found  in  Nippur.  Its  age  may  be 
approximately  placed  at  2250  b.  c.  Eecent  excavations  that  have  been 
made  near  Nippur  and  Babylon  have  brought  to  light  valuable  informa- 
tion regarding  the  practice  of  medicine  under  Hammurabi,  King  of 
Babylon,  a  contemporary  of  Abraham.  The  clay  tablet  is  written  in 
the  Babylonian  tongue,  which  was  the  official  language  of  diplomatic 
intercourse  from  the  Euphrates  to  the  Nile.  The  contents  of  this  tablet 
refer  to  the  'Vorm"  theory  of  dental  caries,  and  the  treatment  consists 
in  filling  the  painful  cavity  of  the  tooth  with  a  cement  prepared  by 
mixing  powdered  henbane  seed  with  gum  mastic.  In  Egypt  the  suet  of 
the  crocodile,  locally  applied,  was  believed  to  relieve  pain,  and  Pliny 
refers  casually  to  the  mystic  lapis  memphitis,  the  stone  of  Memphis, 
which,  when  rubbed  o]i  the  surface  of  tlie  skin  in  conjunction  with  sour 
wine,  was  said  to  produce  local  anesthetic  effects.  In  an  early  Cymric 
manuscript,  which  was  probably  written  about  the  end  of  the  fifteenth 
century,  among  a  large  number  of  conjectures  we  find  the  following: 
"How  to  extract. a  tooth  without  pain:  Take  some  newts,  by  some  called 
lizards,  and  those  nasty  beetles  Avhich  are  found  in  ferns  in  the  summer- 
time. Calcine  them  in  an  iron  pot,  and  make  a  powder  thereof.  Wet 
the  forefinger  of  the  right  hand,  and  insert  it  in  the  powder,  and  apply 

535 


536  ANESTHESIA 

it  to  the  tooth  frequently,  refraining  from  spitting  it  off,  when  the  tooth 
will  fall  away  without  pain.    It  is  proven." 

In  the  early  days  of  modern  dentistry  we  meet  with  many  feeble 
efforts  to  alleviate  pain  during  trying  operations.  The  search  for  new 
methods  and  means  pressed  the  mysticism  of  the  electric  current  into 
service,  opening  to  the  charlatan  a  prolific  field,  which,  even  to  this  day, 
has  not  lost  its  charm.  Eichardson's  voltaic  narcotism  for  a  time  at- 
tracted the  attention  of  the  medical  profession;  and  Francis,  in  1858, 
recommended  the  attachment  of  the  electric  current  to  the  forceps  for 
the  painless  extraction  of  the  teeth.  As  dental  depots  still  offer  aj)pli- 
ances  of  this  nature  for  sale,  it  seems  that  the  method  is  still  in  vogue 
with  some  operators. 

Various  drugs  were  employed,  chloroform,  alcohol,  ether,  opium,  and 
the  essential  oils,  either  simply  or  as  compounds,  usually  under  fanci- 
ful names.  Snape's  "calorific"  fluid,  composed  of  chloroform,  tincture 
of  lemon  balm,  and  oil  of  cloves;  "nabolis,"  consisting  of  glycerite  of 
tannic  acid  and  a  small  quantity  of  chloral  hydrate ;  Morton's  "letheon," 
which  was  ether  mixed  with  aromatic  oils,  are  examples  of  proprietary 
preparations  which  enjoyed  quite  a  reputation  in  their  time. 

In  1853  Alexander  Wood  introduced  a  method  of  general  medica- 
tion by  means  of  hypodermic  injections.  It  was  at  once  suggested  to  em- 
ploy such  drugs  as  morphin  or  tincture  of  opium  for  the  purpose  of  pro- 
ducing local  anesthesia.  The  results  were  not  encouraging,  however, 
until  Koller,  in  1884,  advocated  cocain.  With  the  introduction  of  this 
drug  into  therapeutics,  local  anesthesia  achieved  results  which  were  be- 
yond expectations,  and  its  adoption  created  a  new  era  in  local  anes- 
thesia. 

Local  anesthesia  may  be  obtained  in  two  definite  ways:  (1)  By  in- 
hibiting the  function  of  the  peripheral  nerves  in  a  circumscribed  area 
of  tissue,  this  process  being  called  "terminal  anesthesia";  (2)  by  block- 
ing the  conductivity  of  a  sensory  nerve  trunk  somewhere  between  the 
brain  and  the  periphery,  termed  "conductive  anesthesia."  Conductive 
anesthesia  may  be  produced  by  injecting  into  the  nerve  trunk  proper — 
endoneural  injection — or  by  injecting  into  the  tissues  surrounding  a 
nerve  trunk — perineural  injection.  The  latter  form  is  the  usual  method 
pursued  when  conductive  anesthesia  for  dental  purposes  is  indicated. 

The  Hypodermic  Method. — The  successful  practice  of  local  anesthesia 
in  dental  surgery  involves  the  careful  correlation  of  a  number  of  impor- 
tant details,  each  one  constituting  a  definite  factor  in  itself,  the  neglect 
of  which  must  necessarily  result  in  failure.  As  a  whole,  the  practice  of 
local  anesthesia  by  the  hypodermic  method  represents  the  composite  of 
the  following  factors :  ( 1 )  A  solution  of  active  ingredients  correspond- 
ing to  the  physical  and  physiological  laws  which  govern  certain  func- 
tions of  the  living  cell;  (2)  a  carefully  selected  hypodermic  armamen- 


LOCAL  ANESTHESIA  AS  APPLIED  IN  DENTISTRY  537 

tarium;  (3)  a  complete  mastery  of  the  technique;  (4)  a  proper  selec- 
tion of  the  method  suitable  for  the  case  on  hand;  (5)  good  Judgment 
of  prevailing  conditions. 

Cold. — Physically  reducing  the  temperature  of  the  body  by  the  appli- 
cation of  cold  (ice-pack,  ice  and  salt  mixture,  cold  metals,  etc.)  was 
practiced  by  the  older  surgeons.  Arnott,  in  1849,  and  Blumdell,  in  1855, 
advocated  ice-packs  for  the  painless  extraction  of  teeth. 

Through  the  efforts  of  Sir  B.  W.  Eichardvson,  in  186G,  this  method 
was  placed  on  a  rational  basis  by  the  introduction  of  his  ether  spray. 
To  obtain  good  results,  an  ethyl  ether  free  from  water  is  necessary. 

Certain  other  carbon  compounds  possess  similar  properties  in  vary- 
ing degrees,  depending  on  their  individual  boiling  points.  In  1867 
Eottenstein  called  attention  to  the  use  of  ethyl  chlorid  as  a  refrigerat- 
ing agent,  and  Ehein,  in  1889,  introduced  methyl  chlorid  for  the  same 
purpose.  In  1891  Eedard  reintroduced  ethyl  chlorid  as  a  local  anes- 
thetic. It  has  since  been  marketed  under  various  trade  names,  as  anti- 
dolorin,  kelene,  locodolor,  etc.  Mixtures  of  methyl  and  ethyl  chlorids, 
in  various  proportions  known  as  anesthyl,  anestile,  coryl,  meth-ethyl, 
etc.,  have  been  extensively  used  in  minor  oral  and  general  surgery.  A 
pure  ethyl  chlorid  is  best  suited  for  this  purpose,  as  it  lowers  the  tem- 
perature of  the  tissues  sufficiently  to  produce  a  short  superficial  anes- 
thesia in  a  few  minutes.  Too  rapid  cooling  or  prolonged  freezing  by 
methyl  chlorid  or  the  various  mixtures  thereof  produce  deeper  anesthesia, 
but  such  procedures  are  dangerous.  They  frequently  cut  off  circulation 
in  the  affected  part  so  completely  as  to  produce  sloughing  (necrosis). 

Liquid  nitrous  oxid,  liquid  or  solid  carbon  dioxid  (known  as  carbon 
dioxid  snow),  and  liquid  air  have  been  recommended  for  similar  pur- 
poses. However,  they  require  cumbersome  apparatus,  and  are  extremely 
dangerous. 

Mode  of  Application  of  Ethyl  Chlorid. — For  the  extraction  of  teeth, 
immediate  removal  of  the  pulp,  opening  of  abscesses,  and  other  minor 
operations  about  the  oral  cavity,  the  ethyl  chlorid  tube  should  be  warmed 
to  body  temperature  by  placing  it  in  heated  water,  and  its  capillary  end 
should  be  held  about  six  to  ten  inches  from  the  field  of  operation.  The 
distance  depends  upon  the  size  of  the  orifice  of  the  nozzle,  and  com- 
plete vaporization  should  always  be  produced.  The  Gebauer  tube  ^  is 
fitted  with  a  spray  nozzle,  which  shortens  the  distance  to  one  or  two 
inches,  and  is  especially  well  adapted  for  dental  purposes.  The  stream 
is  directed  upon  the  tissues  until  the  latter  are  covered  with  ice  crys- 
tals and  have  turned  white.  For  the  extraction  of  teeth,  the  liquid 
should  be  projected  directly  upon  the  surface  of  the  gum,  as  near  to 
the  apex  of  the  root  as  possible,  but  care  should  be  taken  to  protect  the 
crown  of  the  tooth  on  account  of  the  painful  action  of  cold  on  this  part. 

iSee  Figure  224,  page  538. 


538.  ANESTHESIA 

The  tissues  to  be  anesthetized  should  first  be  dried  and  well  surrounded 
by  a  film  of  vaselin  or  glycerin,  and  protected  by  cotton  rolls  and  nap- 
kins, to  prevent  the  liquid  from  running  into  the  throat  (Fig.  224) ,  The 
patient  should  breathe  through  the  nose.  Occasionally  light  forms  of 
general  anesthesia -are  introduced  by  inhaling  the  vapor. 

Precautions. — On  account  of  the  difficulty  of  directing  the  stream  of 
ethyl  chlorid  upon  the  tissue  in  the  posterior  part  of  the  mouth,  it  is 
not  successfully  applied  to  those  regions.     The  intense  pain  produced 


Fig.  224. — Application  of  the  Ethyl  Chlorid  Spray. 

by  the  extreme  cold  prohibits  its  use  in  pulpitis  and  acute  pericementitis. 
To  anesthetize  the  second  and  third  branches  of  the  fifth  nerve,  it  is  rec- 
ommended to  direct  the  stream  of  ethyl  chlorid  upon  the  cheek  in  front 
of  the  tragus  of  the  ear,  but  the  author  has  not  seen  any  good  results 
from  such  a  procedure. 

Caution  should  be  exercised  in  using  ethyl  chlorid  near  an  open 
flame  or  in  conjunction  with  the  thermo-cautery ,  as  severe  burns  have 
resulted  by  setting  the  inflammable  vapor  on  fire. 


COCAIN 

Cocain,  when  injected  into  the  tissues,  produces  typical  local  and 
general  effects.  Locally,  it  possesses  a  definite  affinity  for  the  peripheral 
nerves;  it  causes  constriction  of  the  smaller  arteries,  producing  light 
anemia  in  the  injected  area,  with  diminished  action  of  the  leukocytes. 
However,  different  parts  of  the  organism  require  different  doses  to  bring 
about  the  same  reaction.  Upon  mucous  surfaces,  paralysis  of  the  sensory 
nerves  is  produced;  the  senses  of  touch  and  smell  are  temporarily  in- 


LOCAL  ANESTHESIA  AS   APPLIED   IN   DENTISTRY  539 

hibited.  The  blood,  as  such,  and  the  circulation  suffer  little.  If  cocain 
in  sufficient  quantities  is  absorbed  by  the  circulation,  general  manifesta- 
tions are  produced  from  bringing  other  tissues  in  close  contact  with  tlie 
poison.  The  principal  disturbances  of  the  central  nervous  system  make 
themselves  known  by  vertigo,  a  very  slight  pulse,  enlarged  and  staring 
pupils,  and  difficult  respiration.  Vomiting  may  occur;  the  throat  feels 
dry.  Intense  excitement  is  followed  by  epileptiform  spasms;  finally, 
complete  loss  of  sensation  and  mobility  results,  which  terminates  in 
death  from  cessation  of  respiration. 

Precautions. — With  our  increased  knowledge  of  the  action  of  cocain 
upon  the  tissues,  and  with  proper  technique  of  injection,  dangerous  re- 
sults are  comparatively  rare  at  present.  Xo  direct  chemical  antidotes 
are  known,  and  the  treatment  of  general  intoxication  is  purely  symp- 
tomatic. Anemia  of  the  brain,  which  is  of  little  consequence,  may  be 
readily  overcome  by  placing  the  patient  in  a  recumbent  position  or  by 
complete  inversion  if  necessary.  As  a  powerful  dilator  of  the  peripheral 
vessels,  the  vapors  of  amyl  nitrite  are  exceedingly  useful;  it  is  best  ad- 
ministered by  placing  three  to  five  drops  of  the  fluid  upon  a  napkin 
and  holding  it  before  the  nostrils  for  inhalation.  The  flushing  of  the 
face  and  an  increase  in  the  frequency  of  the  pulse  follow  almost  momen- 
tarily. For  convenience,  amyl  nitrite  may  be  procured  in  small  glass 
capsules,  holding  the  quantity  necessary  for  one  inhalation.  JSTausea 
may  be  remedied  by  administering  small  doses  of  spirit  of  peppermint, 
aromatic  spirit  of  ammonia,  or  validol.  To  overcome  the  disturbances 
of  respiration,  quickly  instituted  artificial  respiration  is  the  alpha  and 
omega  of  all  methods  of  resuscitation.  The  only  drug  that  has  proved 
to  be  of  value  in  this  connection  is  strychnin  in  the  form  of  sulphate,  or 
the  nitrate  in  full  doses  by  means  of  hypodermic  injections. 

Preparation  of  Cocain  Solutions. — The  relative  toxicity  of  a  given 
quantity  of  cocain  solution  depends  upon  the  concentration  of  the  solu- 
tion. Eeclus  and  others  have  clearly  demonstrated  that  a  fixed  quantity 
of  cocain  in  a  5  per  cent  solution  is  almost  as  poisonous  as  five  times  the 
same  quantity  in  a  0.5  per  cent  solution.  From  the  extensive  literature 
on  the  subject,  we  are  safe  in  fixing  the  strength  of  the  solution  for 
dental  purposes  at  1  per  cent.  This  quantity  of  cocain  low^ers  the  freez- 
ing point  of  distilled  water  just  a  little  above  0.1°  C.  To  obtain  an  iso- 
tonic solution,  corresponding  to  the  freezing  point  of  the  blood,  0.8  per 
cent  of  sodium  chlorid  must  be  added. 

Having  thus  prepared  a  cocain  solution  wdiich  is  equal  to  the  blood 
in  its  osmotic  pressure  upon  the  cell  wall,  it  is  now  necessary  to  aid 
the  slightly  vasoconstrictor  power  of  the  drug  by  the  addition  of  a  mod- 
erate quantity  of  adrenalin,  thus  increasing  the  confinement  of  the  solu- 
tion to  the  injected  area  by  producing  a  deeper  anemia.  The  purpose  of 
this  is  twofold:     (1)    To  act  as  a  means  of  increasing  the  anesthetic 


540  ANESTHESIA 

effect  of  cocain;  (2)  to  lessen  its  toxicity  upon  the  general  system  by 
slower  absorption.  As  stated  above^  one  drop  of  adrenalin  solution 
added  to  1  c.  c.  of  the  isotonic  cocain  solution  is  sufficient  to  produce 
the  desired  effect. 

A  suitable  solution  for  dental  purposes  may  be  prepared  as  follows: 

R     Cocain  liydrochlorid    5  grains   (  0.3    gm.) 

Sodium    chlorid     4  grains   (   0.25  gm.) 

Sterile  water   1  fluid  ounce   (30.0  c.  c.) 

To  each  syringeful  (2  c.  c.)  add  two  drops  of  adrenalin  chlorid  solution  when 

used. 

Sterilization  of  Solutions. — Eeady-made  cocain  solutions  may  be 
sterilized  only  with  difficulty;  they  will  not  keep  when  frequently  ex- 
posed to  the  air.  The  ready-made  anesthetic  solutions  found  in  the 
market  usually  contain  preservatives  such  as  phenol,  naphthol,  boric 
acid,  iodin,  essential  oils,  alcohol,  etc.,  in  variable  quantities.  Some 
of  these  solutions  have  a  distinct  acid  reaction.  While  they  may  produce 
a  serviceable  degree  of  anesthesia,  they  usually  damage  the  injected  tis- 
sues sufficiently  to  retard  the  normal  process  of  wound  healing.  For 
sterilization,  see  Chapters  XV,  XVIII. 

Substitutes  Proposed  for  Cocain. — Since  the  introduction  of  cocain 
into  the  materia  mediea  for  the  purpose  of  producing  local  anesthesia, 
various  substitutes  have  been  placed  before  the  profession,  superiority  in 
one  respect  or  another  being  claimed  for  each  over  the  original  cocain. 
The  more  prominent  members  of  this  group  are  tropacocain,  eucain  B, 
acoin,  nirvanin,  alypin,  stovain,  novocain,  and,  very  recently,  quinin 
and  urea  hydrochlorid.  (See  Chapter  XX.)  None  of  these  compounds, 
with  the  exception  of  novocain,  has,  in  the  opinion  of  the  author,  proved 
satisfactory  for  the  purpose  in  view. 

Novocain  is  about  two  to  six  times  less  toxic  than  cocain.  It  does 
not  irritate  in  the  slightest  degree  when  injected;  consequently  no  pain 
is  felt  from  its  injection  'per  se.  It  is  soluble  in  its  own  weight  of 
water ;  it  combines  with  adrenalin  in  any  proportion,  without  interfering 
with  the  physiological  action  of  the  latter,  and  it  is  readily  absorbed  by 
the  mucous  membrane.  The  studies  of  Biberfield  and  Braun  brought 
to  light  another  extremely  interesting  factor  concerning  the  novocain- 
adrenalin  combination.  Both  experimenters,  working  independently  of 
each  other,  observed  that  the  adrenalin  anemia  on  the  one  hand,  and  the 
novocain  anesthesia  on  the  other,  were  markedly  increased  in  their 
total  effects  upon  the  tissues.  Consequently  a  smaller  quantity  of  this 
combination  is  required  to  produce  a  given  therapeutic  effect  than  is  re- 
quired of  each  individual  drug.  Very  recently  it  has  been  shown  by 
Esch  that  adrenalin  possesses  a  specific  action  upon  nerve  tissue,  viz.: 
it  affects  the  latter  tissue  in  a  peculiar  manner  so  that  it  will  take  up  the 


LOCAL  ANESTHESIA  AS  APPLIED  IN  DENTISTRY  541 

anesthetic  more  readily.  Its  action  may  be  compared  to  a  mordant  or 
fixing  agent  such  as  is  used  in  tissue  staining.  The  effects  of  the  injec- 
tion of  such  solutions  of  the  combined  drugs  are  usually  confined  to  the 
injected  area;  general  effects  are  therefore  rarely  produced. 

A  suitable  solution  of  novocain  for  dental  purposes  may  be  prepared 
as  follows: 

Novocain    10  grains   (0.6  gm.) 

Sodium    chlorid    4  grains   (0.25  gm.) 

Distilled  water 1  fluid  ounce   (30  c.  c.) 

Boil 

To  each  syringeful  (2  c.  c.)  add  two  drops  of  adrenalin  chlorid  solu- 
tion when  used.  Fischer  strongly  advocates  the  following  so-called 
"normal  anesthetic  solution,"  which,  when  prepared  under  strict  aseptic 
precautions  and  when  preserved  in  amber-colored  bottles,  will  keep : 

Novocain     23  grains   (1.5  gm.) 

Sodium   chlorid    14  grains   (0.92  gm.) 

Thymol    1/3  grain     (0.02  gm.) 

Distilled  water 3  fluid  ounces,  1%  fluid  drams   (100  c.  c.) 

To  each  cubic  centimeter  add  one  drop  of  synthetic  suprarenin  solu- 
tion when  used.  A  sterile  solution  may  be  made  extemporaneously  by 
dissolving  the  necessary  amount  of  novocain-adrenalin  in  tablet  form  in 
a  given  quantity  of  boiled  distilled  water.  A  suitable  tablet  may  be  pre- 
pared as  follows: 

Novocain     1/3  grain  (0.022  gm.) 

Suprarenin  hydrochlorid   1  /1200  grain  (0.000054  gm.) 

Sodium  chlorid 1/8  grain  (0.008  gm.) 

One  tablet  dissolved  in  20  minims  of  sterile  water  makes  a  2  per  cent 
solution  of  novocain  ready  for  immediate  use. 

Solutions  for  hypodermic  purposes  should  preferably  be  made  fresh 
when  needed.  A  small  glass  dish  and  a  dropping  bottle  constitute  the 
simple  outfit  for  such  work.  The  dropping  bottle  should  hold  from  one 
to  two  ounces,  and  should  be  provided  with  a  dust  cap.  On  one  suitable 
bottle  on  the  market,  "a  groove  on  one  side  of  the  neck  of  the  bottle 
and  a  vent  on  the  other  connected  with  two  grooves  in  the  back  of  the 
stopper  allow  the  contents  to  flow  out  drop  by  drop.  A  quarter  turn 
of  the  stopper  closes  the  bottle  tightly."  The  water  used  for  making 
the  solution  should  be  boiled  and  filtered  distilled  water. 

Directions. — The  hyjoodermic  solution  can  be  made  extemporaneousl}' 
in  a  few  seconds^,  as  follows :    Place  a  tablet  in  a  sterile  glass  dish,  add 


542 


ANESTHESIA 


Fig. 


225. — Outfit  for  Preparing  the  Hypoder- 
mic Solution. 


20  minims  (1  c.  c.)  of 
water,  and  to  facilitate 
the  solution  mash  the  tab- 
let. The  solution  is  now 
ready  for  immediate  use. 
The  Hypodermic  Ar- 
mamentarium.— The  Syr- 
inge.— A  hypodermic  syr- 
inge that  answers  all  den- 
tal purposes  equally  well  is 
an  important  factor  in 
carrying  out  the  correct 
technique  of  the  injection. 
The  injection  into  the 
dense  gum  tissue  requires 
from  15  to  50,  or  even 
more,  pounds  of  pressure 
as  registered  by  an  inter- 
posed dynamometer,  while  in  pressure  anesthesia  100  or  more  pounds 

are  frequently  applied. 

The  selection  of  a  suitable  hypodermic 

syringe    is   largely    a    matter    of    choice. 

All-glass    syringes,    glass-barrel    syringes, 

and  all-metal  syringes  are  the  usual  types 

found  in  the  dental  depots.    After  testing 

most  of  the  dental  hypodermic  syringes 

offered  to  the  profession  within  the  last 

five  years  by  means  of  the  pressure  gauge, 

and    in     clinical    work    subjecting    the 

syringes   to   routine   wear   and   tear,   the 

author  has  found  that  an  all-metal  syringe 

of  the  Imperial  type  is  to  be  preferred  to 

other  makes.     They  are  usually  made  of 

nickel-plated  brass,  which,  however,  is  a 

disadvantage,  as  the  nickel  readily  wears 

off  from  the  piston,  and  exposes  the  easily 

corroded  brass.     The  Manhattan  all-metal 

platinoid  syringe  gives  the   best  general 

service,  and  the  author  can  conscientiously 

recommend    it    to    his    confreres.      The 

syringe  holds  40  minims  (2  c.  c),  is  pro- 
vided with  a  strong  finger  cross-bar,  and 

is  extremely   simple  in  construction.      The  piston  consists  of   a  plain 

metal  rod,  without  a  thickened  or  ground  piston  end  or  packing.     The 


Fig. 


226. — Dental   Hypodermic 
Syringe. 


LOCAL  ANESTHESIA  AS  APPLIED  IN  DENTISTRY  543 

piston  rod  is  sufficiently  long  to  allow  about  two  inches  of  space  between 
the  cross  bar  and  the  piston  top.  This  space  is  of  importance,  as  it 
allows  the  last  drop  of  the  fluid  to  be  expelled  under  heavy  pressure 
without  tiring  the  fingers. 

Needles. — Dental  hypodermic  needles  should  be  made  preferably  of 
seamless  steel,  or,  better  still,  of  nickel-steel,  26  to  28  B.  &  S.  gauge,  and 
provided  with  a  short  razor-edge  point.  Thicker  needles  cause  unneces- 
sary pain,  and  thinner  needles  are  liable  to  break.  Iridio-platinum 
needles  are  preferred  by  some  operators,  as  they  may  be  readily  sterilized 
in  an  open  flame.  The  needle  should  measure  from  a  quarter  to  a  half 
inch.  For  infiltration  anesthesia  one-inch  needles  are  necessary,  and 
curved  needles  of  various  shapes  are  essential  in  reaching  the  posterior 
parts  of  the  mouth.  For  pressure  anesthesia  special  needles  are  required, 
and  may  be  bought  at  the  depots,  or  they  may  be  quickly  prepared  by 
grinding  off  the  steel  needle  at  its  point  of  reinforcement.  The  sterile 
needle  should  be  kept  in  well-protected  glass  containers.  The  needles 
are  sterilized  after  each  use  by  boiling  in  plain  water,  dried  with  the 
hot-air  syringe,  and  immediately  transferred  to  a  covered  sterile  glass 
dish.  The  sterile  needles  should  not  be  again  touched  with  the  fingers, 
and  the  customary  wire  insertion  is  unnecessary. 

TECHNIQUE    OE    INJECTION 

Various  methods  of  injecting  the  anesthetic  solution  about  the  teeth 
are  in  vogue.  For  the  sake  of  convenience  they  may  be  divided  as  fol- 
lows: (1)  The  subperiosteal  injection;  (2)  the  peridental  injection; 
(3)  the  intra-osseous  injection;  (4)  the  perineural  injection;  (5)  the 
injection  into  the  pulp. 

Preliminary  Steps. — Before  starting  any  surgical  interference  in  the 
mouth,  the  field  of  operation  should  be  thoroughly  cleansed  with  an 
antiseptic  solution.  A  thin  coat  of  the  official  tincture  of  iodin  painted 
over  the  surface  is  very  useful  for  this  purpose.  After  the  diagnosis  is 
made,  the  method  of  injection  best  suited  for  the  case  on  hand  is  then 
decided  upon. 

The  Subperiosteal  Injection. — The  subperiosteal  injection  about  the 
root  of  an  anterior  tooth  is  best  started  by  inserting  the  needle  midway  be- 
tween the  gingival  margin  and  the  approximate  location  of  the  apex.  The 
pain  of  the  first  puncture  may  be  obviated  by  using  a  fine,  very  sharp- 
pointed  needle,  by  the  simple  compression  of  the  gum  tissue  with  the 
finger  tip,  by  holding  a  pledget  of  cotton  saturated  with  the  prepared 
anesthetic  solution  on  the  gum  tissue  for  a  few  moments,  or  by  applying 
a  very  small  drop  of  liquid  phenol  on  the  point  of  puncture.  The  needle 
opening  faces  the  bone,  the  syringe  is  held  in  the  right  hand  at  an  acute 
angle  with  the  long  axis  of  the  tooth,  while  the  left  hand  holds  the  lip 


544 


ANESTHESIA 


and  cheek  out  of  the  way.  After  puncturing  the  mucosa,  a  drop  of  the 
liquid  is  at  once  deposited  in  the  tissue,  and  the  further  injection  is 
painless.  Slowly  and  steadily  the  needle  is  forced  through  the  gum  tis- 
sue and  periosteum  (Fig.  227)  along  the  alveolar  bone  toward  the  apex 
of  the  tooth,  depositing  the  fluid  under  pressure  close  to  the  bone  on  its 
upward  and  return  trip.    The  continuous  slow  moving  of  the  needle  pre- 


<*^^r 

m 

1 

■ 

„^  *■■■•■ 

xyBwan 

^ 

"•Wk..i»„j( 

*»?v 

1 

^f'^'^H^^^',^^ 

V  J 

-  m 

^^H^^Hplx ,  , 

WJIT'  ''^fy.,,, 

■ 

f A  ^W 

^^hHH 

I^^^H^H 

w^^^^^^^tt 

I 

■ 

Fig.   227. — Method   of  Injection  into   the   Labial   Subperiosteal   Gum   Tissue. 


vents  injecting  into  a  vein.  A  second  injection  may  be  made  by  par- 
tially withdrawing  the  needle  from  the  puncture  and  swinging  the 
syringe  anteriorly  or  posteriorly,  as  the  case  may  be,  from  the  first  route 
of  the  injection.  This  latter  method  is  especially  indicated  in  injecting 
around  the  upper  molars.  After  removing  the  needle,  place  the  finger 
tip  over  the  puncture  and  slightly  massage  the  injected  area.  A  circular 
elevation  outlines  the  injected  field.  The  naturally  pink  color  of  the 
gum  will  shortly  (Fig.  228)  change  to  a  white  anemic  hue,  indicating  the 
physiological  action  of  the  adrenalin  on  the  circulation.  No  wheal 
should  be  raised  by  the  fluid,  as  that  would  indicate  superficial  infil- 
tration and,  consequently,  failure  of  the  anesthetic, 

ExTEACTioisr. — As  the  liquid  requires  a  definite  length  of  time  to  pass 
through  the  bone  lamina  and  to  reach  the  nerves  of  the  peridental  mem- 
brane and  the  pulp,  from  5  to  10  minutes  should  be  allowed  before  the 


LOCAL  ANESTHESIA  AS  APPLIED   IN  DENTISTRY  545 

extraction  is  started.  The  length  of  time  depends  on  the  density  of  the 
surrounding  structure  of  the  tooth.  The  progress  of  the  anesthesia  may 
be  tested  with  a  fine-pointed  probe,  and  its  completeness  indicates  the 
time  when  the  extraction  should  be  started. 

Technique  foe  Different  Teeth. — The  upper  eight  anterior  teeth 
usually  require  a  labial  injection  only,  while  the  molars  require  both  a 
buccal  and  a  palatine  injection,  using  a  slightly  curved  needle  for  tliis 


Fig.  228. — Method  of  Injecting  into  the  Palatine  Subperiosteal  Gum  Tissue. 

purpose.  Buccally  the  injection  is  made  midway  between  the  mesial 
and  distal  root,  and  on  the  palatine  side  over  the  palatine  root. 

The  lower  eight  anterior  teeth  are  comparatively  easily  reached  by 
the  injection.  The  straight  needle  is  inserted  near  the  apex  of  the  tooth, 
the  syringe  is  held  in  a  more  horizontal  position,  and  the  injection  pro- 
ceeds as  outlined  above. 

The  loiver  molars  require  a  buccal  and  lingual  injection.  The 
curved  needle  is  inserted  midway  between  the  roots,  the  gum  margin, 
and  the  apices.  The  external  and  internal  oblique  lines  materially  hin- 
der the  ready  penetration  of  the  injected  fluid,  and  therefore  ample  time 
should  be  allowed  for  its  absorption. 

If  two  or  more  adjacent  teeth  are  to  be  removed,  the  injection  by 
means  of  infiltrating  the  area  near  the  gum  fold  directly  over  the  apices 
of  the  teeth  is  to  be  preferred.     It  is  advisable  to  use  a  one-inch  needle 


546 


ANESTHESIA 


for  this  purpose,  holding  the  syringe  in  a  horizontal  position,  so  as  to 
reach  a  larger  field  with  a  single  injection. 


Fig.  229. — Subperiosteal  Injection  about  an  Upper  Cuspid. 

Abscesses. — Injection  into  inflamed  tissues,  into  an  abscess,  and 
into  phlegmonous  infiltration  about  the  teeth  is  to  be  avoided.     Injec- 


FiG.   230. — Subperiosteal  Injection  about  an  Upper  Molar. 


tion  into  engorged  tissue  is  very  painful;  the   dilated  vessels  quickly 
absorb  cocain  without  produ(;ing  a  complete  anesthesia,  and  general  poi- 


LOCAL  ANESTHESIA  AS  APPLIED  IN  DENTISTRY 


547 


soning  may  be  the  result.  In  purulent  conditions  ijijcction  is  decid- 
edly dangerous,  as  it  forces  the  infection  beyond  the  line  of  demarca- 
tion. If  the  abscess  presents  a  definite  outline,  the  injection  has  to  be 
made  into  the  sound  tissue  surrounding  the  focus  of  infiltration.  If  a 
tooth  is  affected  with  acute  diffuse  or  purulent  pericementitis,  a  distal 
and  a  mesial  injection  usually  produce  successful  anesthesia  by  blocking 
the  sensory  nerve  fibers  in  all  directions. 

Peridental   Anesthesia. — Teeth   or   roots   standing   singly,   or   teeth 

affected     by    pyor- 

rhea,  or  similar 
chronic  peridental 
disturbances,  are 
frequently  quickly 
and  satisfactorily 
anesthetized  by  in- 
jecting the  fluid  di- 
rectly into  the  peri- 
dental membrane. 
This  method  is 
known  as  periden- 
tal anesthesia,  and 
its  technique  i  s 
very  simple.  In 
single-rooted    teeth 

a  fine  and  short  hypodermic  needle  is  inserted  under  the  free 
margin  of  the  gum,  or  through  the  interdental  papilla,  into  the  peri- 
dental membrane  between  the  tooth  and  the  alveolar  wall.  Sometimes 
the  needle  may  be  forced  through  the  thin  alveolar  bone  so  as  to  reach 
the  peridental  meml)rane  direct.  To  gain  access  to  this  membrane  in 
teeth  set  close  together,  slight  se^^aration  with  an  orange-wood  stick  or 
other  suitable  means  is  often  found  to  be  of  advantage.  Two,  some- 
times three,  injections  are  necessary.  To  force  the  liquid  into  the  mem- 
brane usually  requires  a  higher  pressure  than  that  Avhich  is  necessary 
for  injecting  into  the  periosteum  covering  the  alveolar  process,  but  the 
quantity  of  the  anesthetic  liquid  is  less  than  that  which  is  required  for 
the  former  injection.  Acute  inflammatory  conditions  of  the  peridental 
membrane  and  its  sequelae  prohibit  the  use  of  this  method.  Peridental 
anesthesia  is  one  of  the  most  satisfactory  forms  of  local  anesthesia,  since 
the  seat  of  the  nerve  supply  of  the  tooth  is  very  quickly  reached,  and,  as  a 
consequence,  the  results  obtained  are  in  the  majority  of  cases  extremely 
satisfactory,  provided  that  general  conditions  justify  its  application. 

Intra-osseous  Injection. — The  gum  tissue  is  thoroughly  cleansed  with 
an  antiseptic  solution,  and  is  then  anesthetized  about  the  neck  of  the 
tooth  in  the  usual  manner.     x\fter  waiting  2  or  3  minutes,  an  opening 


Fig.    231. — Peridental 


Injection    about    an    Upper    Bi- 
cuspid. 


548 


ANESTHESIA 


is  made  into  the  gum  tissue  and  the  bone  on  the  buccal  side  with  a  fine 
spear  drill  or  a  Gates-Glidden  drill.  The  opening  should  be  made  more 
or  less  at  a  right  angle  with  the  long  axis  of  the  toothy  a  little  below 
the  apical  foramen  in  single-rooted  teeth  or  between  the  bifurcation  in 
the  molars.  The  right-angle  hand  piece  is  preferably  employed  for  this 
purpose.  The  drill  should  be  of  the  same  diameter  as  the  hypodermic 
needle.  The  gum  fold  is  tightly  stretched  to  avoid  laceration  from  the 
rapidly  revolving  drill.  As  soon  as  the  alveolar  process  is  penetrated,  a 
peculiar  sensation  conveyed  to  the  guiding  hand  indicates  that  the 
alveolus  proper  is  reached,  and  the  sensation  felt  by  the  hand  is  about 
the  same  as  that  experienced  when  a  burr  enters  into  the  pulp  chamber. 
In  this  artificial  canal  the  close-fitting  curved  needle  of  the  hypodermic 
syringe  is  now  inserted,  and  the  injection  is  made  in  the  ordinary  way. 
The  quantity  of  fluid  used  is  much  less  than  is  usually  needed  for  a 
subperiosteal  injection.  The  roots  of  the  teeth  are  imbedded  in  a  sieve- 
like mass  of  bone  tissue  (diploe),  which  allows  a  ready  penetration  of 
fluid  when  injected  under  pressure. 

Perineural  Injection. — For  the  anesthetization  of  a  number  of  teeth 
in  the  upper  or  the  lower  jaw,  conductive  anesthesia  by  means  of  peri- 


14 

1 

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1 

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^ 

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/ 

^,- 

^'^^-^;* 

1 

Fig.  232. — Perineural  Injection  upon  the  Buccal  Side  of  the  Upper  Jaw.  A,  B, 
injection  below  the  infra-orbital  foramen;  A^  B\  injection  over  the  region  of  the 
tuberosity. 


neural  injection  is  preferably  employed.  The  perineural  injection  is 
made  near  the  point  of  exit  or  entrance  of  the  various  nerves  about  their 
respective  foramina.  To  anesthetize  all  the  teeth  of  one-half  of  the  upper 
jaw,  4  injections  are  necessary,  i.  e.,  2  buccally  and  2  on  the  palatine 
side  of  the  bone.    A  1-inch  needle  is  required  for  such  work.     To  reach 


LOCAL  ANESTHESIA  AS   APPLIED   IN   DENTISTRY  549 

the  many  small  branches  of  the  posterior  dental  nerves  at  the  alveolar 
foramina,  the  injection  is  made  bnccally  over  the  region  of  the  tuberosity 
about  14  ii^ch  above  the  gingival  line  between  the  first  and  second  molar 
teeth.  The  second  injection  is  made  below  the  intra-orbital  foramen, 
so  as  to  reach  the  middle  and  anterior  dental  nerves.  With  the  index 
finger  of  the  left  hand  the  foramen  is  approximately  located  by  exerting 
pressure  upon  the  nerve  exit.  The  lip  is  lifted  up  with  ihe  middle 
finger  of  the  same  hand,  and  the  needle  is  now  inserted  between  the 
apices  of  the  cuspid  and  first  bicuspid  teeth.  The  needle  is  slowly 
pushed,  forward  until  its  point  is  felt  beneath  the  finger  tip.  To  reach 
the  nerve  supply  of  the  hard  palate,  one  injection  is  made  near  the  pos- 
terior palatine  canal,  and  the  other  near  the  foramina  of  Scarpa.  The 
great  palatine  nerves  pass  through  the  posterior  palatine  canals  on  both 
sides  of  the  hard  ]3alate.  The  canals  lie  about  %  of  an  inch  above  the 
edge  of  the  alveolar  process  and  the  last  molar  tooth.  They  move  pos- 
teriorly with  the  eruption  of  the  successive  teeth.  The  nasopalatine 
nerves  pass  through  the  foramina  of  Scarpa  (incisive  foramen),  which 
are  situated  in  the  line  of  the  suture  of  the  maxillary  bones.  If  an 
imaginary  line  is  drawn  from  the  distal  borders  of  the  two  cuspids,  pass- 
ing over  the  hard  palate,  it  will  ordinarily  pass  through  the  foramina. 
The  needle  should  be  inserted  directly  back  of  the  pa|)illa,  which  lies  pos- 
teriorly between  the  central  incisor  teeth. 

To  anesthetize  one-half  of  the  mandible,  three  injections  for  the 
deposition  of  the  anesthetic  solution  are  necessary.  The  first  injection 
is  applied  near  the  mandibular  foramen,  the  second  near  the  mental 
foramen,  and  the  third  into  the  incisive  fossa.  To  locate  the  mandibu- 
lar foramen  in  the  mouth  the  lingual  surface  of  the  ramus  is  palpated 
with  the  finger,  the  anterior  sharp  border  of  the  coronoid  process  is 
easily  felt  about  %  of  an  inch  posterior  to  the  third  molar.  The  process 
passes  downward  and  backward  from  the  third  molar,  and  enters  into 
the  external  oblique  line.  Mesially  from  this  ridge  is  to  be  found  a  small 
triangular  concave  plateau,  wdiich  is  facing  downward  and  outward, 
being  bound  mesially  by  a  distant  bony  ridge  and  covered  with  mucous 
membrane.  As  there  is  no  anatomical  name  attached  to  this  space, 
Braun  has  called  it  the  retromolar  triangle  (trigonum  retromolare).  In 
the  closed  mouth  it  is  located  at  the  side  of  the  upper  third  molar,  and 
in  the  open  mouth  it  is  found  midway  between  the  upper  and  lower 
teeth.  Immediately  back  of  the  mesial  border  of  this  triangle,  directly 
beneath  the  miicous  membrane,  lies  the  lingual  nerve,  and  about  three- 
eighths  of  an  inch  further  back  the  mandibular  nerve  is  to  be  found. 
This  last  nerve  lies  close  to  the  bone,  and  enters  into  the  mandibular 
foramen,  which  is  partially  covered  by  the  mandibular  spine. 

Before  starting  the  injection,  the  patient  should  be  cautioned  to  rest 
his  head  quietly  on  the  headrest  of  the  chair,  as  any  sudden  movement 


550 


ANESTHESIA 


or  interference  with  the  hand  of  the  operator  may  be  the  cause  of  break- 
ing the  Jieedle  in  the  tissues.  The  syringe,  provided  with  a  1-inch 
needle,  is  held  in  a  horizontal  position,  resting  on  the  occluding  surfaces 
of  the  teeth  from  the  cuspid  backward  and  sliglitly  toward  the  median 
line.  The  needle  is  to  be  inserted  three-eighths  of  an  inch  above  and  the 
same  distance  back  of  the  occluding  surface  of  the  third  lower  molar, 


Fig.  233. — Perineural  Injection  upon  xhe  Hard  Palate.      A,  B,  injection  near  the 
foramina  of  Scarpa;  C,  D,  injection  near  the  posterior  palatine  canals. 


the  needle  opening  facing  the  bone.  This  position  will  insure  the  cor- 
rect direction  of  the  needle  point,  so  as  to  reach  the  tissues  immediately 
surrounding  the  nerves,  and  not  lose  the  injection  in  the  adjacent  thick 
muscle  tissue.  The  needle  must  always  be  in  close  touch  with  the  bone, 
and  is  noAV  slowly  pushed  forward,  depositing  a  few  drops  of  fluid  on  its 
way  until  the  ridge  is  reached.  About  five  drops  of  fluid  are  injected 
in  this  immediate  neighborhood  for  the  purpose  of  anesthetizing  the 
lingual  nerve.  The  needle  is  now  pushed  very  slov/ly  forward,  always 
keeping  in  close  touch  Avith  the  bone  and  depositing  fluid  on  its  way, 
until  it  is  pushed  in  about  five-eighths  of  an  inch.  It  is  important  to 
carefully  feel  the  way  along  the  bony  Avail  of  the  ramus,  as  the  needle 
may  have  to  pass  over  the  roughened  and  bony  elevations  which  afford 


LOCAL  ANESTHESIA  AS  APPLIED  IN  DENTISTRY  551 

attachment  to  the  internal  pterygoid  muscle.  During  the  injection  the 
syringe  should  remain  in  the  same  horizontal  position  as  heretofore  out- 
lined. Soon  after  the  injection,  paresthesia  of  one-half  of  the  tongue  on 
the  side  of  the  injection  occurs,  which  is  soon  followed  hy  anesthesia  of 
the  mandibular  nerve.  Paresthesia  of  the  mucous  membrane  and  half 
of  the  lower  lip  is  also  established.  The  pulps  of  the  lower  teeth,  in- 
cluding the  cuspid. and  lateral  incisor,  the  gum  tissue  on  both  sides  of 
the  jaw,  and  a  part  of  the  anterior  floor  of  the  mouth  are  anesthetized. 
The  complete  anesthesia  of  the  two  nerves  also  anesthetizes  the  whole 
alveolar  process  in  this  region.  About  five  minutes  are  required  for  the 
complete  anesthetization  of  the  lingual  nerve,  and  at  least  fifteen  min- 


FiG.  234. — Perineural  Injection  Near  the  Mandibular 
Foramen. 

utes  for  the  mandibular  nerve.  Braun  claims  that  the  injection  is  abso: 
lutely  free  from  danger,  while  Eoemer  states  that  danger  may  arise  if 
the  whole  quantity  of  the  solution  should  accidentally  be  injected  into  a 
vein. 

The  mental  foramen  lies  midway  between  the  superior  and  inferior 
border  of  the  body  of  the  mandible  on  its  external  surface,  usually  below 
the  second  bicuspid  teeth.  Its  opening  always  faces  posteriorly.  An 
injection  near  this  point  increases  the  anesthesia  in  the  cuspid  region. 
The  incisive  fossa  is  a  shalloAV  depression  on  the  external  surface  of  the 
mandible  between  the  cuspid  teeth.  It  may  be  located  by  the  palpating 
finger  immediately  above  the  chin.  A  number  of  small  foramina  are 
found  in  this  region  for  the  passage  of  nerves  aiid  nutrient  vessels.  The 
lower  incisors  may  be  anesthetized  by  making  injections  anteriorly  into 
the  incisive  fossa,  and  one  posteriorly  in  the  region  corresponding  to 
the  fossa.  Usually  peridental  anesthesia  is  to  be  preferred  for  these 
teeth. 

Precautions. — Conductive  anesthesia  is  serviceable  if  a  number  of 
teeth  have  to  be  removed  at  one  visit.  It  should  be  borne  in  mind,  how- 
ever, that  in  the  average  case  onhj  one-half  of  either  jaw  should  be  anes- 


552  ANESTHESIA 

thetized  at  one  sitting,  so  as  to  keep  the  quantity  of  the  injected  anes- 
thesia solution  within  the  limits  of  ordinary  dosage. 

The  Injection  into  the  Pulp. — By  pressure  anesthesia,  pressure  cata- 
phoresis,  or  contact  anesthesia,  as  the  process  is  variously  termed,  we 
understand  the  -  introduction  of  a  local  anesthetizing  agent  in  solution 
by  mechanical  means  through  the  dentine  into  the  pulp  for  the  purpose 
of  rendering  it  insensible  to  pain.  Simple  hand  pressure  with  a  suitable 
instrument,  the  hypodermic  syringe,  or  the  so-called  high-pressure 
syringe,  is  recommended  for  such  purposes. 

Methods  of  Anesthetizing  the  Pulp. —  (1)  The  pulp  is  wholly  or 
partially  exposed.  The  tooth  is  isolated  with  rubber  dam,  and  cleaned 
with  water  and  alcohol.  The  cavity  is  excavated  as  much  as  possible, 
and,  if  the  pulp  is  not  exposed,  it  is  dehydrated  with  alcohol  and  hot  air. 
A  pledget  of  cotton  or  a  piece  of  spunk  is  saturated  with  a  concentrated 
cocain  or  novocain  solution,  placed  into  the  prepared  cavity,  and  covered 
with  a  piece  of  vulcanizable  rubber.  With  a  suitable  burnisher,  slowly 
increasing,  continuous  pressure  is  applied  for  from  1  to  3  minutes.  The 
pulp  may  now  be  exposed  and  tested.  If  it  is  still  sensitive,  the  process 
is  repeated.  Loeffler  states  that  "this  pressure  may  be  applied  by  taking 
a  short  piece  of  orange  wood,  fitting  it  into  the  cavity  as  prepared,  and 
directing  the  patient  to  bite  down  upon  this  with  increasing  force.  In 
this  way  we  can  obtain  a  well-directed  regulated  force  or  pressure  with 
less  discomfort  to  the  patient  and  operator."  Miller  describes  this 
process  as  follows :  "After  excavating  the  cavity  as  far  as  convenient, 
and  smoothing  the  borders  of  it,  take  an  impression  in  modeling  com- 
pound, endeavoring  to  get  the  margins  of  the  cavity  fairly  well  brought 
out ;  put  a  few  threads  of  cotton  into  the  cavity  and  saturate  them  thor- 
oughly with  a  five  to  ten  per  cent  solution  of  cocain;  cover  this  with  a 
small  bit  of  rubber  dam,  and  then  press  the  compound  impression  down 
upon  it.  We  obtain  thereby  a  perfect  closure  of  the  margin,  so  that  the 
liquid  cannot  escape,  and  one  can  then  exert  pressure  with  the  thumb 
sufficient  to  press  the  solution  into  the  dentin." 

(2)  The  pulp  is  covered  with  a  thick  layer  of  healthy  dentin.  AVith 
a  very  small  spade  drill,  one  bores  through  the  enamel  or  direct  into  the 
dentin  at  the  most  convenient  place,  guiding  the  drill  in  the  direction  of 
the  pulp  chamber.  The  chips  are  blown  out,  the  cavity  dehydrated  with 
alcohol  and  hot  air,  and  the  syringe,  provided  with  a  special  needle, — 
making  as  nearly  as  possible  a  water-tight  joint, — is  applied.  Slow,  con- 
tinuous pressure  is  applied  for  from  two  to  three  minutes.  With  a 
round  burr  the  pulp  should  not  be  exposed,  and,  if  still  found  sensitive, 
the  process  is  repeated. 

Recently  a  method  has  come  into  vogue  which  allows  successful  anes- 
thetization of  the  pulp  by  injecting  the  anesthetic  solution  around  the 
apex  of  the  tooth.     The  spongy  alveolar  process,  which  contains  lymph 


LOCAL  ANESTHESIA  AS  APPLIED  IN   DENTISTRY  553 

channels,  allows  the  ready  penetration  of  the  fluid.  The  injection 
should  be  made  close  to  the  bone,  the  needle  being  pushed  slowly  toward 
the  apex,  while  the  fluid  is  deposited  drop  by  drop.  IS^o  wheal  should  be 
raised  by  the  injection,  otherwise  the  benefit  of  the  pressure  from  the 
dense  gum  tissue  is  lost. 


CHAPTER    XV 

SPINAL  ANALG.ESIA  AND   SPINAL  ANESTHESIA 

William  Seaman  BainbkidgE;,  Sc.D.,  M.D, 

Introduction. 
.  History  :  Discovery  of  and  Experimentation  with  Cocain ;  Experi 
mentation  with  Cocain  from  the  Neurological  Point  of  View  with  Ee- 
gard  to  Its  Analgesic  Effects  Upon  the  Sensory  Nerves,  Including  the 
Spinal  Cord;  Application  of  the  Analgesic  Effects  of  Cocain  Upon  the 
Cord  to  Surgical  Operations  Below  the  Diaphragm;  Extension  of  the 
Surgical  Application  of  Spinal  Analgesia  to  Parts  of  the  Body  Above  the 
Diaphragm ;  Experimentation  with  Other  Agents. 

Anatomical  and  Physiological  Considerations:  Origin;  Vol- 
ume; Specific  Gravity;  Movements;  Pressure;  Diffusion. 

Course,  Extent,  and  Duration  of  Analgesia  :  Course  ;  Extent  ; 
Duration. 

Accompanying  Phenomena :    Subjective;  Objective. 

Postoperative  Phenomena. 

Indications  and  Contraindications. 

Advantages  and  Disadvantages  :    Advantages ;  Disadvantages. 

Deaths. 

Analgesic  Agents  :    Cocain ;  Tropacocain ;  Stovain ;  Novocain. 

Sterilization  of  the  Analgesic  Agent. 

Sites  of  Injection. 

The  Patient  :  Preliminary  Preparation  of  Patient ;  Position  of  Pa- 
tient. 

Apparatus  and  Materials. 

Technique  of  Injection. 

Additional  Illustrative  Case  Reports. 

Conclusion. 

INTRODUCTION 

In  the  pages  which  follow  the  term  analgesia  (dv  +  aXyos)  is  em- 
ployed with  its  strict  etymological  significance — absence  of  sensibility  to 
pain.  The  broader  term,  anesthesia  {dv  +  ato-^T/o-is) — without  sensation 
— is  purposely  avoided,  except  when  quoting  from  authors  who  make  no 

554 


SPINAL    ANALGESIA    AND    SPINAL    ANESTHESIA        555 

differentiation,  and  when  referring  to  the  exceptional  eases  in  which 
analgesia  merges  into  anesthesia. 

Complete  loss  of  sensation  comes  only  with  narcosis  {msm>idyd)  — 
a  state  of  profound  unconsciousness.  In  some  instances,  witii  heavy 
dosage,  an  analgesic  agent  injected  into  the  subarachnoid  space  may 
produce  a  state  of  mental  lethargy  bordering  upon  that  which  follows 
the  inhalation  of  an  anesthetic  agent,  with  the  loss  of  all  forms  of  sensa- 
tion— a  real  anesthesia.  As  a  rule,  however,  with  moderate  dosage,  the 
analgesic  agent  introduced  into  the  spinal  canal  gives  rise  only  to  anal- 
gesia— loss  of  sensibility  to  pain.  Tactile  sense,  the  sense  of  heat  and 
cold,  of  pressure  and  of  traction,  are  not  completely  destroyed  in  the 
latter  case. 

The  operator  who  fails  to  bear  in  mind  the  above  differentiation  is 
apt  to  experience  more  or  less  difficulty  at  times,  and  to  feel  that  he  has 
a  right  to  chronicle  dissatisfaction  or  failure  with  the  method  under  dis- 
cussion. 

It  has  been  our  purpose  to  give,  as  briefly  as  possible,  in  the  pages 
which  follow,  a  cursory  review  of  the  work  of  others,  rather  than  to  con- 
fine ourselves  strictly  to  the  limits  of  personal  experience.  With  spinal 
analgesia,  as  with  every  other  form  of  analgesia  or  anesthesia,  the  method 
has  its  enthusiastic  adherents  and  its  uncompromising  opponents.  We 
have  endeavored,  in  the  light  of  personal  experience,  to  examine  the  evi- 
dence pro  and  con,  and  to  give  a  fair  and  impartial  statement  of  our 
findings. 

HISTORY 

The  history  of  spinal  analgesia  may  be  divided,  for  purposes  of  con- 
venience, into  four  periods,  which  are  more  or  less  overlapping  in  time 
and  achievement:  (1)  Discovery  of  and  experimentation  with  cocain; 
(2)  experimentation  with  cocain  from  the  neurological  point  of  view, 
with  regard  to  its  analgesic  effects  upon  sensory  nerves,  including  the 
spinal  cord;  (3)  application  of  the  analgesic  effects  of  cocain  upon  the 
cord  to  surgical  operations  below  the  diaphragm;  (4)  extension  of  the 
application  of  spinal  analgesia  to  parts  of  the  body  above  the  diaphragm. 
Experimentation  with  other  agents. 

Discovery  of  and  Experimentation  with  Cocain.— The  discovery 
by  Niemann,  in  1859,  of  the  alkaloid  of  coca  leaves,  to  which  the  name 
cocain  was  given,  may  be  said  to  mark  the  first  event  in  the  history  of 
spinal  analgesia. 

The  discovery  by  Schraff',  in  1862,  of  the  local  analgesic  properties  of 
this  substance  when  placed  upon  the  tongue  was  the  second  step  forward 
in  the  history  of  this  method. 

With  the  application  of  the  latter  discovery  to  surgical  purposes,  sug- 


556  ANESTHESIA 

gested  by  Koller,^  in  1884,  the  history  of  spinal  analgesia  was  fairly  in- 
itiated. 

Following  immediately  upon  these  discoveries  and  their  announce- 
ment,2  many  experiments  were  undertaken  by  investigators  throughout 
Europe  and  America,  all  having  for  their  motive  the  production  of  local 
analgesia  for  surgical  purposes.  This  particular  phase  of  the  general 
subject  of  anesthesia  falls  within  the  scope  of  the  chapter  on  local  anal- 
gesia. It  concerns  the  history  of  spinal  analgesia  only  in  so  far  as  the 
discovery  and  application  of  cocain  by  others  led  to  the  sequence  of  de- 
ductive reasoning  by  Corning,  and  furnished  the  means  for  the  applica- 
tion of  the  theories  by  which  he  gave  to  the  world  the  discovery  of  spinal 
analgesia. 

Experimentation  with  Cocain  from  the  Neurological  Point  of 
View  with  Regard  to  Its  Analgesic  Effects  Upon  the  Sensory  Nerves, 
Including  the  Spinal  Cord. — Coming's  brilliant  work  ^  on  the  prolonga- 
tion of  the  analgesic  effects  of  cocain  subcutaneously  administered  v/as 
the  logical  antecedent  to  his  equally  brilliant  experiments  with  the  local 
medication  of  the  cord.* 

In  his  first  paper  on  spinal  analgesia  Corning  was  influenced  in  his 
deductions  by  the  work  of  Harley,'^  who  showed  that  a  poison  sijch  as 
strychnin,  injected  under  the  membrane  covering  the  cord,  "can  act 
only  through  the  intermediation  of  the  blood  vessels,  since,  when  the 
latter  are  separated  from  the  cord,  the  solution  remains  entirely  inert." 

Corning  concluded  from  this  that,  "in  order  to  obtain  the  most  im- 
mediate, direct,  and  powerful  effects  upon  the  cord  with  a  minimum 
quantity  of  a  medicinal  substance,  it  is  by  no  means  necessary  to  bring 
the  substance  into  direct  contact  with  the  cord;  it  is  not  necessary  to 
inject  the  same  beneath  the  membranes,  as  in  the  case  of  the  frogs,  since 
the  effects  are  entirely  due  to  the  absorption  of  the  fluid  by  the  minute 
vessels.  On  the  other  hand,  in  order  to  obtain  these  local  effects,  it  is 
first  necessary  to  inject  the  solution  in  the  vicinity  of  the  cord;  sec- 

^  Roller,  Karl :  ' '  On  the  Use  of  Cocaine  to  Anesthetize  the  Eye, ' '  Wiener 
med.  Woch.,  Oct.  25,  Nov.  1,  1884.  Translated  by  H.  Knapp:  "Cocaine  and  Its 
Uses  in  Ophthalmic  and  General  Surgery."    Putnam's  Sons,  N.  Y.,  1885. 

^  Noyes,  Henry  D. :  "A  Few  Cursory  Notes  on  the  Proceedings  of  the  Meet- 
ing of  the  German  Ophthalmol ogical  Society,  Held  at  Heidelberg  in  the  Middle 
of  September  of  This  Year."    Med.  Bee,  Oct.  11,  1884. 

^Corning:  (1)  "On  the  Prolongation  of  the  Aneesthetic  Effects  of  the 
Hydrochlorate  of  Cocaine  When  Subcutaneously  Injected.  An  Experimental 
Study."  N.  Y.  Med.  J.,  Sept.  19,  1885;  (2)  "The  Author's  Method  of  Local 
Ansesthetizatipn  by  Incarceration  of  the  Anaesthetic  in  the  Field  of  Operation, ' ' 
Part  II,  "Local  Anaesthesia,"  34. 

*  Corning :  ' '  Spinal  Anaesthesia  and  I'ocal  Medication  of  the  Cord,  "A.  Y. 
Med  J.,  Oct.  31,  1885,  Eeprinted,  1909,  72,  790.     Also  in  "Local  Anaesthesia,"  85. 

''See  Ringer,  Sidney:     "A  Handbook  of  Therapeutics,"   1870,   387. 


SPINAL    ANALGESIA    AND    SPINAL    ANESTHESIA        557 

ondly,  to  select  such  a  spot  as  will  insure  the  most  direct  possible  entry 
of  the  fluid  into  the  circulation  about  the  cord." 

He  reasoned  that,  if  placed  between  the  spinous  processes  of  the 
vertebrae,  "the  anesthetic  would  be  rapidly  absorbed  by  the  minute 
ramifications  of  the  veins  referred  to,  and,  being  carried  by  the  blood 
to  the  substance  of  the  cord,  would  give  rise  to  anesthesia  of  its  sensory 
and  perhaps  also  of  its  motor  tracts.'^ 

It  was  with  this  conception  of  the  matter  that  Corning  carried  out 
his  early,  experiments,  first  upon  a  dog  and  then  upon  a  man. 

In  the  case  of  the  man,  who  was  suffering  from  spinal  weakness  and 
seminal  incontinence,  30  minims  of  a  3  per  cent  solution  of  cocain  were 
injected  between  the  spinous  processes  of  the  eleventh  and  twelfth 
dorsal  vertebrse. 

These  experiments  encouraged  Corning  to  proceed  with  his  investi- 
gations, and  in  1888  he  published  a  report  ^  of  his  injection  of  cocain 
hydrochlorate  in  the  immediate  neighborhood  of  the  cord. 

The  injections  were  made  in  the  lumbar  and  dorsal  regions,  and  thus 
Corning,  antedated  by  three  years  the  work  of  Quincke  ^  with  lumbar 
puncture. 

Quincke  found,  independently,  being  unaware  of  Coming's  work, 
that  it  was  possible  to  remove  the  cerebrospinal  fluid  after  lumbar  punc- 
ture apparently  without  danger  to  the  subject.  He  also  demonstrat- 
ed that  a  considerable  amount  of  the  cerebrospinal  fluid  may  be  with- 
drawn. 

Quincke's  experiments  were  made  with  a  partly  different  object  in 
view  from  that  which  actuated  Corning,  but  the  former's  discovery  un- 
doubtedly had  its  effect  in  stimulating  interest  in  the  subject  of  spinal 
puncture,  as  it  concerned  the  induction  of  spinal  analgesia. 

Following  the  work  of  Corning  and  Quincke,  various  experiments 
were  made  with  reference  to  the  effect  of  medicinal  fluids  upon  the 
spinal  nerves  and  cord. 

Ziemssen  ^  proposed  the  injection  of  such  substances  through  lumbar 
puncture. 

Sicard,*  in  1898,  published  the  report  of  a  series  of  experiments  in 
which  he  injected  into   the   subarachnoid   space   normal   salt  solution, 

^  Corning :  ' '  Further  Contribution  on  Local  Medication  of  the  Spinal  Cord, 
with  Cases."  Med.  Bee,  March  17,  1888;  also  ''Headache  and  Neuralgia,"  1888, 
157. 

-  Quincke :  ' '  Die  Lumbalpunktur  des  Hydrocephalis. ' '  Berl.  Min.  Woch., 
1891,  No.  38. 

^Ziemssen:      Wiesbaden  Kongr.,  1893. 

"Sicard:  "Essais  d 'injections  microbiennes,  toxiques  et  therapeutiques, 
par  voie  cephalo-rachidienne. "  Compt.  rend.  Soc.  de  Biol.,  Paris,  April  30,  1898; 
also  ' '  Toxine  et  antitoxine  tetanique  par  injections  sous-arachnoidiennes, ' '  ibid., 
Nov.  12,  1898. 


558  ANESTHESIA 

tetanus  toxin,  niorphin,  and  other  substances,  and  later  he  reported  ^ 
the  results  of  his  investigations  concerning  the  toxic  effects  of  cocain 
when  introduced  into  the  subarachnoid  space  through  the  intracranial 
or  spinal  route. 

From  his  first  series  of  experiments  Sicard  concluded  that  the 
subarachnoid  space  could  receive  relatively  large  quantities  of  fluid,  and 
that  the  effects  of  such  fluid  injected  in  this  manner  varied  in  propor- 
tion to  the  amount  of  dilution  and  to  the  rapidity  with  which  the  solu- 
tion was  injected. 

Independent  investigations  by  Jaboulay  ^  confirmed  Sicard's  conclu- 
sions. 

Corning,  meanwhile,  was  still  pursuing  his  experimental  studies,  and 
in  1894  he  published  the  details  of  his  method  of  irrigating  the  cauda 
equina  with  medicinal  fluids.^ 

While  he  was  engaged  in  testing  his  method  of  medicating  the  spinal 
cord.  Corning  became  impressed  with  the  desirability  of  introducing  the 
remedies  directly  into  the  spinal  canal,  "with  a  view  to  producing  still 
more  powerful  impressions  upon  the  cord,  and  more  especially  upon  its 
lower  segment." 

"There  can  be  no  doubt,"  he  states,  "especially  if  the  injection  be 
made  between  the  second  and  third  lumbar  vertebrae,  that  the  functions 
of  the  lower  segments  of  the  cord  itself  may  be  powerfully  affected  in 
this  manner.  We  have  only  to  conceive  of  the  cerebrospinal  fluid  being 
at  this  point  thoroughly  impregnated  with  the  medicinal  fluid  and 
lying  in  direct  contact  with  the  pia  ...  to  be  convinced  of  the  potency 
of  such  a  procedure." 

The  dangers  involved  in  such  an  operation  were  made  a  matter  of 
consideration  by  Corning,  and  his  own  observations  were  in  accord  with 
the  work  of  Mitchell  *  and  Thoburn.^ 

Mitchell  showed  that  a  simple  puncture  of  a  nerve  of  an  animal  with 
a  sharp  needle  causes  little  bleeding,  which  passes  away  without  grave 
results. 

Thoburn  called  attention  to  the  harmlessness  of  such  slight  trauma- 
tism as  the  pricking  of  the  cauda  equina. 

This  work  was  later  verified  by  Crile's  investigations.^     He  found, 

^Sicard:  "Inoculations  sous-arachnoidiennes  chez  le  chien;  voie  cranienne, 
voie  rachidienne, ' '  Compt.  rend.  Soc.  de  Biol.,  Paris,  Oct.  29,  1898 ;  also  ' '  In- 
jection sous-arachnoidienne  de  cocaine  chez  le  chien,"  ibid.,  May  20,  1899. 

^Jaboulay.  "Drainage  de  I'espace  sous-arachnoidienne  et  injection  de 
liquides  medicamenteux  dans  les  meninges, ' '  Lyon  med.,  May  15,  1898. 

'Corning:      "Pain,"  1894,  247  et  seq. 

■'Mitchell,  S.  Weir:   "Injuries  of  Nerves  and  Their  Consequences,"  1872. 

"Thoburn,  William:     "Injuries  of  the  Cauda  Equina,"  Brain,  10,  381  et  seq. 

'  Crile :  ' '  An  Experimental  and  Clinical  Kesearch  into  Certain  Problems  Ee- 
lating  to  Surgical  Operations,"  1901, 


SPINAL    ANALGESIA    AND     SPINAL    ANESTHESIA        559 

from  a  series  of  recovery  experiments,  that  it  was  difficult  to  locate  the 
point  of  injection,  and  that  it  was  only  in  cases  where  no  aseptic  pre- 
caution's had  been  taken  at  the  time  of  the  injection  that  the  track  of 
the  needle  could  be  traced  by  the  unaided  eye,  careful  inspection  failing 
to  reveal  the  point  of  injection  in  cases  where  such  precautions  had  been 
taken. 

Corning  ^  emphasized  the  fact  that  serious  disturbances  of  sensation 
and  mobility,  having  their  origin  in  the  cauda  equina,  are  always  due  to 
gross  lesions,  and  not  to  insignificant  circumscribed  causes. 

Application  of  the  Analgesic  Effects  of  Cocain  Upon  the  Cord  to 
Surgical  Operations  Below  the  Diaphragm. — The  studies  of  Corning 
seem  to  have  made  little  or  no  impression  upon  the  minds  of  the  various 
investigators  to  whose  experiments  reference  has  been  made.  Despite 
the  fact  that  he  had  suggested,  in  his  original  contribution,  the  surgical 
application  of  the  method,^  no  such  application  had  been  made  until 
Bier,  of  Kiel,  demonstrated  its  entire  feasibility  and  published  the  re- 
sults of  his  work.^  Odier,*  who  injected  cocain  into  the  spinal  cord  of 
rabbits,  noting  the  resulting  protoplasmic  changes  in  the  nerve  cells  and 
the  analgesia  of  the  body  below  the  point  of  the  injection,  failed  to  make 
any  clinical  application  of  the  latter  finding. 

With  the  publication  of  Bier's  paper  the  surgical  application  of  spinal 
analgesia  was  definitely  estaljlished. 

Bier  observed  the  effects  of  analgesia  induced  by  this  method  upon 
himself,  his  assistants,  and  six  patients.  Lumbar  puncture,  after  the 
method  of  Quincke,  was  employed.  The  passage  of  the  needle  was  ren- 
dered painless  by  means  of  Schleich's  infiltration.  He  used  two  cubic 
centimeters  of  a  one  per  cent  solution  of  cocain. 

The  appearance  of  Bier's  paper  led  to  the  immediate  adoption  of  the 
method  by  many  surgeons  throughout  the  civilized  world,  but  especially 
in  France  and  America.  His  findings  were  verified  by  Seldowitch,^ 
experimenting  upon  dogs. 

Tait  and  Caglieri  ^  are  credited  with  having  performed  the  first  sur- 

*  Corning:      "Pain,"  1894. 

^Corning:  Oy.  cit.  (N.  Y.  Med.  J.,  Sept.  19,  1885)— "Whether  the  method 
will  ever  find  an  application  as  a  substitute  for  etherization  in  genitourinary  or 
other  branches  of   surgery,   further  experience  alone  can  show." 

*  Bier :  ' '  Versuche  iiber  Cocainisirung  des  Eiickenmarkes, ' '  Deut.  Zeit.  f. 
Chir.,  Leipzig,  1899,  361. 

*  Odier :  '  *  Eeeherches  exp^rimentales  sur  les  mouvements  de  la  cellule  ner- 
veuse  de  la  moelle  epiniere, ' '  Eev.  Med.  de  I.  Suisse  Romande,  1898,  IS,  59. 

*  Seldowitch :  ' '  Ueber  Cocainisirung  des  Eiickenmarkes  nach  Bier, ' '  Ceniralbl. 
f.  Chir.,  1899,  41,  1110. 

*  Tait  and  Caglieri:  "Experimental  and  Clinical  Notes  on  the  Subarach- 
noid Space,"  Trans.  Med.  Soc.  State  of  Cal,  April,  1900,  266.  Also,  /.  Am. 
Med.  Assn.,  July  7,  1900. 


560  ANESTHESIA 

gical  operation  under  spinal  analgesia  in  America,  on  October  26,  1899. 
Osteectomy  of  the  tibia,  in  a  patient  fifty-four  years  of  age,  was  per- 
formed without  pain  or  discomfort,  and  with  no  unpleasant  after-effects. 
One  c.  c.  of  a  %  per  cent  solution  of  cocain  was  employed. 

The  procedure  was  "popularized"  by  Tuffier,^  who  extended  the  appli- 
cation of  the  method  from  its  original  domain  of  the  lower  extremities, 
as  practiced  by  Bier,  to  the  genito-urinary  organs  and  abdomen.  He 
subsequently  performed  hysterectomy,  salpingectomy,  nephrectomy, 
pylorectomy,  cholecystectomy,  etc.,  under  subarachnoid  analgesia. 

The  position  of  spinal  analgesia  in  the  surgical  world  was  established 
upon  a  firm  basis  by  the  work  of  Bier,  Tait  and  Caglieri,  Tuffier,  and 
others  of  the  early  investigators,  and  the  literature  of  the  subject  at 
once  began  to  assume  extensive  proportions.  The  scope  of  the  applica- 
tion of  the  procedure  was  quickly  extended,  and  the  method  came  to  be 
employed  in  old  and  young,  for  divers  conditions,  and  with  varying  de- 
grees of  skill  and  success. 

It  was  not  long  until  Bier  felt  called  upon  to  protest  ^  against  the 
recklessness  with  which  the  method  was  being  employed,  regardless  of 
the  fact  that  no  noteworthy  improvement  in  technique  had  been  evolved. 
He  protested  especially  against  the  dangerously  large  doses  of  cocain 
which  some  operators  used.  New  methods,  he  said,  should  be  devised  in 
an  attempt  to  reduce  the  toxicity  of  the  drug  and  to  prevent  the  un- 
pleasant by-efi^ects  so  often  noted.  He  suggested  the  application  of  the 
procedure  to  operations  upon  the  entire  trunk  and  arms,  and  made  a 
plea  for  an  effort  to  find  less  harmful  drugs  which  would  produce  anal- 
gesia by  this  method. 

In  obstetrical  practice  subarachnoid  analgesia  was  employed  early  in 
its  history,  Kreis  ^  being  credited  with  having  first  made  this  application 
of  the  method.    Doleris,*  Marx,^  Dupaigne,*^  and  others  utilized  the  pro- 

^  Tuffier:  (1)  "Analgesie  chirurgicale  par  I'iiijection  sous-arachnoidienne 
lombaire  de  cocaine,"  Soc.  de  Biol.,  Nov.  11,  1899,  in  Semaine  med.,  1899,  389; 
also,  La  Presse  nled.,  Nov.  15,  1899,  294;  (2)  "L'Analgesie  chirurgicale  par  voie 
rachidienne, "  1900.     In  L'CEuvre  me dico-chirur gical,  Critzman,  1901-02,  24-30. 

^  Bier :  ' '  Bemerkungen  zur  Cocainisirung  des  Eiickenmarkes, ' ' Miinch.  med. 
Woch.,  Sept.  4,  1900,  1226. 

'Kreis:  "Ueber  Medullarnarkose  bei  Gebarenden, "  CentrlM.  f.  Gyn.,  July  14, 
1900,  724. 

*Doleris:  "Analgesie  par  injection  de  cocaine  dans  I'arachnoide  lom- 
baire," Compt.  rend.  d.  I.  Soc.  d'Obst.,  de  Gyn.,  et  d.  Pediat.  d.  Paris,  1900, 
S,  328. 

°Marx:  (1)  "Medullary  Narcosis  During  Labor,  a  Preliminary  Eeport, " 
Med.  News.,  Aug.  25,  1900,  293;  (2)  "Medullary  Narcosis  During  Labor,"  Med. 
Bee,  Oct.  6,  1900,  521;  (3)  "Analgesia  in  Obstetrics  Produced  by  Medullary 
Injections  of  Cocain,"  PMla.  Med.  J.,  Nov.  3,  1900,  857. 

"Dupaigne:  "Anesthesie  rachidienne  par  le  cocaine,"  Ann.  de  Gyn.  et  Obst., 
Paris,  1901,  55,  44. 


SPINAL    ANALGESIA    AND    SPINAL    ANESTHESIA        561 

cedure  for  the  same  purpose.  My  own  experience  with  spinal  analgesia 
in  obstetrical  practice  is  limited  to  one  case,  but  this  was  an  excellent 
one  in  which  to  test  the  method  in  this  class  of  cases.  (See  case  descrip- 
tion on  page  593.) 

In  the  early  stage  of  the  surgical  application  of  spinal  analgesia  the 
author  of  this  section  began  to  employ  the  method,  being  particularly 
interested  at  that  time  in  its  use  in  young  children.  >Seven  cases  oper- 
ated upon  under  spinal  analgesia  were  reported,^  the  youngest  being  21/^ 
and  the  oldest  11  years  of  age.  The  former  case  was  apparently  the 
youngest  in  which  the  method  had  been  employed  at  that  time.  The 
youngest  cases  on  record  at  that  time  were:  One,  8  years,  operated  by 
Murphy;  one  each  at  11  years,  by  Bier,  Lugueu,  and  Kinder jy,  and  one, 
12  years,  by  Tuffier. 

An  additional  series  of  forty  cases  ^  was  reported  during  the  follow- 
ing year,  the  youngest  of  this  series  being  7%,  and  the  oldest  19  years 
of  age.    Twenty-four  of  these  cases  were  reported  in  detail. 

Eeport  ^  was  published  of  twelve  operations  upon  infants  and  young 
children  ranging  in  age  from  3  months  to  5  years.  Of  this  series  the 
history  of  that  case.  No.  XII,  is  detailed  on  page  588. 

Tuffier  ■^  reported  a  case  in  an  infant  3  months  old. 

Extension  of  the  Surgical  Application  of  Spinal  Analgesia  to  Parts 
of  the  Body  Above  the  Diaphragm.  Experimentation  with  Other 
Agents. — It  is  impossible,  within  the  limited  space,  to  follow  the  work 
of  the  very  large  number  of  surgeons  who  have  devoted  attention  to  the 
subject  of  spinal  analgesia  during  the  years  which  have  intervened  since 
the  appearance  of  Bier's  original  communication.^  The  historical  con- 
tributions, other  than  those  mentioned,  have  been  largely  in  the  nature 
of  modifications  of  technique,  and  the  verification  of  the  earlier  results 
by  a  large  number  of  clinical  cases. 

With  certain  notable  exceptions,  both  the  experimental  and  the  clini- 
cal investigations  were  concerned  with  the  production  of  analgesia  below 
the  diaphragm  and  its  application  to  the  surgery  of  those  regions. 

Tait  and  Caglieri,"  in  1900,  reported  3  cases  in  which  cocain  was 
injected  into  the  sixth  cervical  space  without  untoward  effects.     The 

^  Bainbridge :  "Analgesia  in  Children  by  Spinal  Injection,  witli  a  Eeport  of 
a  New  Method  of  Sterilization  of  the  Injection  Fluid,"  Med.  Bee,  Dec.  15, 
1900. 

^Bainbridge:  "A  Eeport  of  Twenty-four  Operations  Performed  During 
Spinal  Analgesia,"  Med.  News,  May  4,  1901. 

'Bainbridge:  "Eeport  of  Twelve  Operations  on  Infants  and  Young  Children 
During  Spinal  Analgesia, ' '  Archives  of  Pediat.,  July,  1901. 

^Tuffier:  "Sur  la  rachicocainisation, "  La  Presse  med.,  Paris,  June  8,  1901, 
265. 

=  Bier:     Op.  cit.,  Pent.  Zeii.  f.  CUr.,  Leipzig,  1899,  51,  361. 

''Tait  and  Caglieri:      Op.  cit..  Trans.  Med.  Soc.  State  Cal.,  April,   1900,  266. 


562  ANESTHESIA 

patients  were  examined  weeks  after  the  injection  and  found  to  be  free 
from  any  complication. 

Morton/  in  1900,  also  presaged  the  recent  extension  of  spinal  anal- 
gesia to  surgicai  operations  upon  all  parts  of  the  body.  "I  think,"  he 
said,  "we  will  soon  find  that,  by  injecting  higher  into  the  dorsal  region, 
anesthesia  can  be  extended  all  over  the  body  with  perfect  safety.  It  has 
been  demonstrated  in  the  dog  by  making  an  injection  in  the  upper  part 
of  the  dorsal  region.  It  does  not  interfere  with  motion,  consciousness,  or 
sense  of  touch." 

In  a  later  communication  ^  Morton  said :  "I  think  we  have  a  safe 
and  reliable  analgesic  in  the  subarachnoid  injection  of  cocain  for  the 
performance  of  any  surgical  operation  on  any  portion  of  the  body,  re- 
gardless of  age,  sex^  or  disease,  and  one  which  has  no  contraindications." 
In  this  report  Morton  tabulated  253  cases  operated  upon  by  him,  24  in 
females,  229  in  males,  8  of  the  operations  being  above  the  diaphragm. 
An  additional  series  of  61  cases  was  added  to  the  above  report,  15  of 
which  were  upon  the  upper  extremities  or  head.  The  analgesia  was  com- 
plete in  all  cases.  One  case  in  which  the  operation  was  above  the  dia- 
phragm was  reported  in  detail.^ 

Chaput  and  others  performed  operations  on  parts  of  the  body  above 
the  diaphragm  under  spinal  analgesia. 

It  appears  that  the  work  of  Tait  and  Caglieri,  Morton,  and  others, 
with  high  injection,  has  not  been  followed  up  with  further  published 
clinical  application,  for  which  reason,  perhaps,  originality  in  this  regard 
has  been  generally  accorded  to  Jonnesco. 

In  September,  1908,  before  the  Congress  of  the  International  Society 
of  Surgery,  in  Brussels,  Jonnesco,*  of  Bucharest,  described  his  new 
method  of  general  spinal  anesthesia,  and  reported  14  cases  operated 
upon  by  this  method.  The  method  is  detailed,  and  selected  cases  cited, 
103  of  which  were  high  dorsal  analgesias,  and  295  dorso-lumbar  anal- 
gesias. 

In  a  later  article  ^  Jonnesco  says :  "It  is  an  error  to  confuse  lumbar 
rachianesthesia,  conceived  by  Corning  and  popularized  by  Bier,  with  my 
method.  As  I  have  many  times  emphasized,  my  method  is  a  new  one 
and  altogether  distinctive,  because  I  have  generalized  spinal  anesthesia, 
adapting  it  to  all  operations  on  any  part  of  the  body.     This  has  not  yet 

^Morton:  "Is  the  Subarachnoidean  Injection  of  Cocain  the  Preferable  Anes- 
thesia Below  the  Diaphragm?"    Pac.  Med.  J.,  Nov.,  1900. 

2  Morton:  "The  Subarachnoid  Injection  of  Cocain  for  Operations  on  All 
Parts  of  the  Body,"  Am.  Med.,  Aug.  3,  1901. 

^  Morton :  ' '  Eeport  of  a  Lipoma  Eemoved  from  the  Cheek  under  Medullary 
Narcosis,"  FMla.  Med.  J.,  July  6,  1901. 

■'Jonnesco:     "Eemarks  on  General  Analgesia,"  Brit.  Med.  J.,  Nov.  13,  1909. 

^Jonnesco:  "Concerning  General  Eachianesthesia, "  Am.  J.  of  Surg.,  1910, 
g9.  33. 


SPINAL    ANALGESIA  ,  AND     SPINAL    ANESTHESIA        563 

been  done  by  others,  although  it  is  now  a  year  and  a  half  since  I  read  a 
paper  on  this  subject  at  the  International  Surgical  Congress  in  Brussels. 
I  secured  this  anesthesia  by  piercing  the  spinal  column  at  all  levels,  and 
by  adding  strychnin  to  the  anesthetic  stovain,  novocain,  tropococain, 
etc." 

Jonnesco  holds  that  the  fact  that  the  respiratory  nerves  are  not  in- 
volved in  the  high  injections,  although  all  the  other  nerves  of  that  spinal 
region,  are  paralyzed,  is  due  to  the  influence  of  the  strychnin.  To  this 
latter  statement  reference  will  be  made  under  the  head  of  physiological 
action. 

In  the  addition  of  the  strychnin  to  the  analgesic  solution  Jonnesco  is 
evidently  original.  As  early  as  1903,  however,  the  author  of  this  sec- 
tion used  strychnin  hypodermatically  in  conjunction  with  spinal  anal- 
gesia, with  the  same  ends  in  view,  of  supporting  the  jDatient  and  pre- 
venting respiratory  depression. 

Following  the  suggestion  of  Bier  concerning  the  desirability  of  dis- 
covering some  more  suitable  drug  than  cocain  for  spinal  analgesia 
(see  page  560),  a  large  amount  of  experimental  work  has  been  done 
with  a  view  to  accomplishing  this  end.  Tropacocain,  stovain,  novocain, 
beta-eucain,  beta-eucain  lactate,  alypin,  nirvanin,  holocain  hydrochlorid, 
acoin,  orthoform  (new),  and  anesthesine  are  some  of  the  drugs  which 
from  time  to  time  have  been  made  the  subject  of  experimental  or  clinical 
investigation.  (See  page  599.)  A  full  list  of  all  substances  which 
have  been  prepared  is  given  in  Chapter  XX. 


ANATOMICAL  AND  PHYSIOLOGICAL  CONSIDERATIONS 

With  the  discovery  by  Cotugno  (Dominicus  Cotunnius),  in  1764,  of 
the  "collection  of  water  about  the  brain  and  in  the  spine,"  a  new  interest 
was  given  to  the  cerebrospinal  column.  The  observations  of  Cotugno 
upon  the  bodies  of  animals  were  confirmed  by  him  upon  human  sub- 
jects, and  his  declaration  that  the  nervous  centers  were  bathed  by  this 
cephalo-spinal  fluid  called  forth  a  brief  but  very  good  description  by 
Haller,  in  1766,  and  a  complete  study  by  Magendie,  in  1825,  Follow- 
ing these  early  investigators,  a  number  of  others  continiied  the  study 
of  the  anatomy  and  physiology  of  the  cerebros^^inal  canal.  Coming's 
experiments  with  reference  to  the  local  medication  of  the  cord,  and  the 
discovery  by  Quincke  that  it  is  possible  to  remove  the  cerebrospinal 
fluid  by  lumbar  puncture  without  danger  to  the  subject,  gave  a  still  more 
definite  interest  to  this  region.  The  surgical  application,  made  by  Bier, 
of  the  discoveries  of  Corning  and  Quincke  called  forth  an  extensive 
series  of  investigations  concerning  the  anatomical  and  physiological  rela- 
tions of  the  vertebral  canal. 


564  ANESTHESIA 

The  extent  of  the  experimental  and  clinical  study  devoted  to  this 
subject  may  be  imagined  when  one  realizes,  as  stated  by  Mott/  that  in 
the  ten  years  preceding  1910  there  appeared  in  the  Revue  Neurologique 
abstracts  of  187  papers  on  the  physiology  of  the  cerebrospinal  fluid. 

Despite  the  many  contributions  to  the  subject,  there  is  a  notable 
diversity  of  opinion  with  reference  to  certain  practical  points  relating 
to  the  physiology  of  the  cerebrospinal  canal  and  its  contents,  as  will  be 
seen. 

Among  the  more  recent  investigators  of  the  anatomical  relations  of 
the  canal,  Gerstcnberg  and  Hein "  and  Lusk  ^  have  given  valuable  practi- 
cal contributions.  Michelson  *  and  others  have  emphasized  the  impor- 
tance of  bearing  in  mind  that  the  spinal  fluid  bathes  a  number  of  cranial 
nerves,  as  well  as  the  spinal  roots,  so  that  those  nerves  may  also  become 
exposed  to  the  toxic  action  of  the  analgesic  agent  when  it  passes  to  a 
sufficient  height  in  the  clural  sac.  The  abducens,  troclihar,  motoroculi, 
and  optic  are  the  cranial  nerves  primarily,  and  most  frequently,  involved 
in  spinal  analgesia. 

It  is  to  be  taken  for  granted  that  the  general  anatomy  of  the  parts 
involved  is  a  matter  of  accurate  knowledge  on  the  part  of  the  surgeon 
who  undertakes  spinal  puncture,  for  which  reason  no  space  is  given  to 
this  subject.  Certain  practical  points  which  are  directly  concerned  in 
the  matter  of  the  selection  of  the  site  for  puncture,  and  in  controversy 
relating  to  lateral  or  median  puncture,  are  reserved  for  the  section  on 
Sites  of  Injection.     (See  p.  605.) 

Physiological  investigation  has  established  certain  facts  with  refer- 
ence to  the  cerebrospinal  fluid  which  have  a  practical  bearing  upon 
spinal  puncture  and  spinal  analgesia.  The  composition,  origin,  density, 
volume,  pressure,  drainage,  and  motion  of  the  fluid  have  been  made  the 
subject  of  exhaustive  research,  formerly  by  physiologists  and  neurolo- 
gists, and  latterly  by  those  especially  interested  in  its  utilization  for 
therapeutic  purposes,  particularly  with  reference  to  spinal  analgesia. 

Origin. — Faivre,  in  1851,  suggested  the  intimate  relationship  between 
the  choroid  plexus  of  the  central  nervous  system  and  the  cerebrospinal 
fluid.  Subsequent  investigation  has  tended  to  support  the  view  that  the 
cerebrospinal  fluid  is  a  secretory  product  of  the  epithelial  cells  of  the 
choroid  plexus  and  of  the  ependyma  membrane. 

^Mott,  F.  W.:  "The  Cerebro-spinal  Fluid,"  Lancet,  July  2  and  9,  pp.  1  and 
79,  1910. 

^  Gerstenberg  and  Hein :  ' '  Anatomische  Beitrage  zur  Riickenmarkesanasthesia, ' ' 
Z.  f.  Gehurtsch.  u.  Gyn.,  1907-08,  61,  .524;  also,  Verhandlungen  der  GesellscJiaft  f. 
Geburtsh.  u.  Gyn.,  zu  Berlin,  1907-08. 

'Lusk,  William  C. :  "The  Anatomy  of  Spinal  Puncture  with  Some  Con- 
siderations on  Technic  and  Paralytic  Sequels,"  Ann.  of  Surg.,  Oct.,  1911,  449. 

*  Michelson:  "Der  gegenwartige  Stand  der  Lumbal-anaesthesie, "  Ergebnisse 
der  Chir.  und  Ortho.,  1912,  4. 


SPINAL    ANALGESIA    AND    SPINAL    ANESTHESIA        565 

Volume. — There  is  abundant  evidence  of  the  fact  that  the  cerebro- 
spinal fluid  is  continually  being  secreted.  The  quantity  in  the  subarach- 
noid space,  the  ventricles  of  the  brain,  and  the  central  canal  of  the  spinal 
cord  is  said  to  vary  from  50  to  150  c.  c,  the  average  being  from  100  to 
130  c.  c.     (See  pp.  619  and  G24  Dry  Spine.) 

Specific  Gravity. — According  to  Gray,  who  studied  the  cerebro- 
spinal fluid  in  a  series  of  normal  children,  from  whom  it  was  obtained 
on  the  operating  table,  the  specific  gravity  varied  from  1.0054  to  1.0071. 
In  cases  of  extreme  shock  the  specific  gravity  rose  to  1.0076,  1.0080,  and 
1.0083.  The  fluid  of  older  children  tended  to  be  of  a  higher  density 
than  that  of  infants  and  younger  children. 

The  specific  gravity  of  the  fluid  in  adults  is  stated  by  ISTogue  -  to  vary 
from,  an  average  of  1.003  to  as  high  as  1.020.  By  the  majority  of  the 
writers  consulted  it  is  stated  to  vary  from  1.004  to  1.007. 

Movements. — The  cerebrospinal  fluid  is  in  constant  motion.  Being 
constantly  secreted,  it  is  likewise  continuously  drained  through  the 
arachnoid  sheaths  of  the  nerves,  the  perivascular  lymphatic  sheaths,  and, 
according  to  some  observers,  the  "Pacchionian  bodies.  This  subject  has 
been  studied  by  Schwalbe,  Key  and  Eetzius,  Tait  and  Caglieri,  Klose 
and  Vogt,  and  a  number  of  others,  and  recently  reviewed  by  Chambard." 

When  sepia,  India  ink,  or  other  colored  fluid  is  injected  into  the 
canal,  the  colored  corpuscles  accumulate  around  the  nerve  roots  and  the 
cranial  nerves  near  their  exit  orifices.  The  elimination  in  this  manner  of 
soluble  substances  injected  into  the  fluid  illustrates  the  meningeal  per- 
meability from  within  outward. 

In  addition  to  the  constant  drainage  of  the  cerebrospinal  fluid  there 
are  also  pulsation,  a  systolic  flux  and  reflux,  and  a  transportation,  under 
certain  circumstances,  of  the  entire  bulk  of  the  fluid,  as  when,  in  tlic 
horizontal  position,  the  fluid  is  transported  on  to  the  medulla  and  the 
brain. 

Pressure. — -The  pressure  under  which  the  fluid  exists  is  dependent 
upon  the  cerebral  circulation,  and  varies  under  certain  circumstances  and 
in  different  positions  of  the  body.  The  actual  pressure  is  taken  by  lum- 
bar puncture  in  the  sitting  posture.  This  has  been  found  by  Quincke  to 
vary  from  50  to  150  millimeters  of  water. 

Diffusion. — Tait  and  Caglieri,*  in  their  valuable  experimental  and 
clinical  work  on  the  subarachnoid  space,  employed  a  large  number  of 

^  Gray,  H.  Tyrrell :  "A  Study  of  Spinal  Angesttesia  in  Children  and  In- 
fants," Lancet,  Sept.  25  and  Oct.  2,  1909. 

^Nogue:     "  Anesthesie, "  Traite  de  StomatoJogie,  1912,  6,  Paris. 

'Chambard:      "  L 'Anesthesie  Lombaire, "    These  de  Paris,   1911. 

*Tait  and  Caglieri:  Op.  cit.,  Trans.  Med.  Soc.  State  of  CaJ.,  April,  1900,  266. 
See,  also,  /.  Am.  Med.  Assn.,  July  7,  1900. 


566  ANESTHESIA 

animals  and  a  series  of  cadavers,  and  several  patients  were  subjected 
by  them  to  lumbar  puncture  for  therapeutic  purj)oseG,  Avith  the  hope  of 
clearing  up  certain  doubtful  points  relating  to  the  physiology  of  the 
subarachnoid  space. 

By  means  of  their  experimental  work  on  animals  and  their  clinical 
studies  on  man,  these  investigators  confirmed  the  theory  that  absorption 
and  elimination  occur  when  chemical  substances  are  injected  directly 
into  the  subarachnoid  space,  and  that  the  osmotic  current  exists  in  only 
one  direction;  in  other  words,  as  shown  by  Sicard,  that  there  is  exos- 
mosis,  but  no  endosmosis. 

The  mode  of  diffusion  of  the  cerebrospinal  fluid  was  studied  by 
means  of  colored  mixtures,  which  enabled  the  workers  to  note  with  ac- 
curacy and  facility  both  the  miscroscopic  and  the  macroscopic  results. 
When  injected  without  pressure,  the  colored  fluid  stained  the  space  at 
the  point  of  injection,  then  diffused  in  all  directions,  ascending  and  de- 
scending, following  the  meningeal  prolongations  along  the  spinal  nerves, 
to  the  intervertebral  foramina,  where  it  stopped  abruptly.  The  extent 
and  the  rapidity  of  the  diffusion  were  influenced  by  the  amount,  the 
composition,  and  the  specific  gravity  of  the  liquid  injected,  and  chiefly 
by  the  pressure  under  which  it  was  injected. 

It  was  foimd  that  a  slow  injection  of  1  c.  c.  of  the  colored  mixture, 
in  a  rabbit  weighing  900  gm.,  ascended  rapidly,  the  fluid  being  found 
around  the  medulla  oblongata  and  at  the  base  of  the  brain  when  the 
animal  was  killed  10  hours  after  the  injection. 

The  same  amount  of  fluid  injected  under  pressure  was  found  2G 
hours  later  to  have  diffused  from  the  spinal  subarachnoid  through  the 
foramen  of  Magendie  to  the  fourth  ventricle,  through  the  iter  a  teriio, 
or  aqueduct  of  Sylvius,  to  the  third  ventricle,  and  finally  to  the  cortex  of 
the  brain.  If  5  c.  c.  of  the  colored  fluid  were  injected  under  great 
■pressure  in  the  lumbar  space,  the  diffusion  occurred  instantaneously. 

Experiments  were  instituted  to  determine  the  course  followed  by  the 
fluid  from  the  lumbar  space  to  the  cortex  of  the  brain.  It  was  found 
that  the  pia-arachnoid  was  colored  in  its  entire  course  along  the 
cord  and  brain,  continuing  along  the  sheath  of  the  auditory,  facial,  and 
optic  nerves,  and  following  the  prolongations  through  the  cribriform 
plate  of  the  ethmoid.  The  stain  followed  the  meningeal  sheath  on  the 
optic  nerve,  generally  stopping  at  the  junction  with  the  sclerotic.  In 
several  of  their  specimens  Tait  and  Caglieri  found  that  the  stain  in- 
volved the  sclerotic,  choroid,  papilla,  and  retina. 

Halbreich,^  from  a  series  of  experiments  on  dogs  and  frogs,  con- 
cluded that  the  solution,  when  injected  in  the  lumbar  region,  is  the 
more  liable  to  reach  the  medulla  oblongata  the  larger  the  quantity  of 
fluid  injected  and  the  more  the  head  of  the  subject  is  lowered.     The 

'Halbreich:     Med.  Oios.,  Eussia.  Abst.  in  J.  Am.  Med.  Assn.,  1902,  603. 


SPINAL    ANALGESIA    AND     SPINAL    ANESTHESIA        567 

gray  matter  is  penetrated,  according  to  this  investigator,  by  diffusion 
and  osmosis,  and  by  the  lymphatics. 

Crile,^  in  his  studies  upon  the  cord,  injected  a  solution  of  cocain, 
which  was  colored  with  methylene  blue.  He  found  that  an  injection  of 
V^  dram  of  this  solution,  made  in  the  lumbar  region,  stained  the  entire 
cord  and  the  under  surface  of  the  brain  in  30  seconds.  The  various 
localized  functions  of  the  cord  and  medulla  were  rapidly  anesthetized, 
the  respiratory  center  in  the  medulla,  for  example,  being  anesthetized 
within  a  few  seconds  l)y  lumbar  arachnoid  injection.  A  forcible  injec- 
tion was  followed  within  a  few  seconds  by  a  direct  fall  in  blood  pressure 
and  by  cessation  of  respiration.  Crile  found  that  the  fluid  ascended 
about  as  rapidly  with  the  subject  in  a  vertical  position  as  in  the  hori- 
zontal, and  he  concluded  that  the  effect  of  the  anesthetic  was  due  to 
local  contact  with  the  nerve  structure,  and  not  to  absorption.  This  view, 
he  held,  is  in  full  accord  vv^ith  the  general  action  of  cocain  on  other 
nerve  structure.  Crile  purposely  employed  large  doses  in  these  experi- 
ments in  order  to  determine  the  control,  or,  as  he  expresses  it,  the  want 
of  control,  the  operator  can  have  over  the  extent  of  the  analgesia. 

The  attempt  to  ascertain  to  just  what  physiological  action  of  the 
analgesic  agent  the  analgesic  state  may  be  attributed  in  the  case  of 
subarachnoid  injection  has  led  to  various  theories  of  more  or  less  con- 
tradictory character. 

Bier  ^  held  that  the  sequence  of  symptoms  following  the  injection  is 
the  result  of  changes  in  the  circulation  caused  by  the  introduction  of  a 
heterogeneous  substance  into  the  spinal  canal,  and  that  it  is  not  due  to 
any  toxic  action  of  the  cocain. 

Nicoletti  ^  attributed  it  to  the  vasomotor  constrictive  action  of  the 
injected  agent. 

Goldan  *  held  that  the  circulation  is  no  factor  in  the  production  of 
analgesia  when  cocain  is  injected  into  the  subarachnoid  space,  the  effects 
being  due,  in  all  probability,  to  the  passage  of  the  cocai-n  from  the 
subarachnoid  space  along  the  perivascular  spaces  in  the  tunica  adven- 
titia  of  the  blood  vessels  to  the  sensory  columns  of  the  cord,  also  directly 
into  the  lymph  spaces  of  the  nerves  themselves. 

The  investigations  of  Donitz  and  Barker  seem  to  have  led  to  different 
conclusions  with  respect  to  the  manner  of  extension  of  the  analgesia. 

^  Crile,.  George  W. :  "An  Experimental  and  Clinical  Eesearch  into  Certain 
Problems  Relating  to  Surgical  Operations."     Phila.,  1901,  145  et  seq. 

^Bier:  "Bemerkungen  zur  Cocainisirung  der  Riickenmarkes, "  Miinch.  med. 
Woch.,  Sept.  4,  1900. 

^  Nicoletti :  "  L  'analgesia  cocainica  del  midollo  spinale  nella  chirurgia  gine- 
cologica, "  Treizieme  Congres  International  de  Med.,  Paris,  Sec.  de  Chir.  Gen., 
1900;  see,  also,  Archiv.  Hal.  di  Ginicol.,  Aug.  1900,  512. 

*  Goldan:  "Intraspinal  Cocainization  for  Surgical  Anesthesia,"  Med.  News, 
Nov.  3,  1900. 


568  ANESTHESIA 

Donitz  ^  maintains  that  it  is  not  a  question  of  diffusion,  but  simply 
one  of  shifting  the  balance  in  the  liquor  spinalis,  which  takes  place  at 
the  moment  of  the  change  of  posture;  that  "it  is  not  a  question  of  the 
action  of .  gravity  on  the  analgesic  compound  at  all,  nor  is  it  one  of 
hypothetic  currents." 

Barker,^  on  the  other  hand,  in  his  interesting  series  of  clinical  ex- 
periments, makes  use  of  gravity  by  employing  an  injection  compound 
of  much  greater  specific  weight  than  that  of  the  liquor  spinalis.  As- 
suming that  there  are  only  three  ways  in  which  an  analgesic  fluid  in- 
jected in  the  second  lumbar  interspace  can  make  its  direct  effects  felt 
in  the  mid-dorsal  region  or  higher.  Barker  says  with  reference  to  these, 
in  sequence: 

"(1)  Diffusion  alone  of  one  fluid  in  another  is  a  slow  process,  and, 
as  we  shall  see,  is  unlikely  to  be  the  mode  of  spread  of  the  injected  fluid 
in  this  procedure. 

"(2)  Bier  and  his  followers  have  aimed  at  shifting  the  whole  in- 
jected compound  upward  or  downward  with  the  whole  mass  of  the  liquor 
spinalis  by  raising  or  depressing  the  pelvis.  That  the  cerebrospinal 
fluid  does  recede  somewhat  toward  the  head  on  elevation  of  the  pelvis 
is  undoubted,  but  it  is  hard  to  imagine  its  doing  so  to  such  an  extent  as 
to  carry  with  it  a  cloud  of  fluid  lighter  than  itself  from  the  second  lum- 
bar to  the  fifth  dorsal  vertebra,  some  8  to  10  inches.  I  venture  to  think 
that  with  such  a  fluid  as  he  has  used,  whose  specific  gravity  is  1.0058, 
suspended  in  the  liquor  spinalis,  whose  specific  gravity  is  1.0070,  what 
he  has  achieved  by  elevation  of  the  pelvis  has  rather  been  a  more  rapid 
diffusion  of  the  injected  drug,  due  to  the  consequent  oscillation  of  the 
spinal  fluid,  aided,  perhaps,  by  vascular  pulsation.  But  this  rapid  diffu- 
sion would,  of  course,  dilute  the  injection,  and  perhaps  carry  it  further 
than  desirable. 

"(3)  There  remains,  then,  the  third  possibility,  namely,  that  an 
injected  compound  heavier  than  the  liquor  spinalis  may  be  affected  by 
gravity,  and  sink  through  the  latter  in  a  way  quite  different  to  the  be- 
havior of  a  fluid  of  less  specific  gravity,  such  as  that  referred  to." 

Other  investigators,  notably  Babcock,^  by  using  an  injection  fluid 
lighter  than  the  cerebrospinal  fluid,  seek  to  affect  the  sensory  nerves 
without  involving  the  motor  nerves.  The  regulation  of  the  position  of 
the  patient's  body,  with  such  a  fluid,  controls  the  area  affected  by  the 

^  Donitz :  ' '  Die  Hohenausdeliung  der  spinal  Analgesic, ' '  Munch,  med.  Woeh., 
Nov.  27,   1906. 

^  Barker :  "A  Report  on  Clinical  Experiences  with  Spinal  Analgesia, ' '  Brit. 
Med.  J.,  March  23,  1907. 

^Babcock,  W.  Wayne:  (1)  "Spinal  Anesthesia.  A  Clinical  Study  of  658 
Administrations,"  Fenn.  Univ.  Med.  J.,  Aug.,  1909;  (2)  "The  Eange  of  Activity 
and  the  Untoward  Effects  of  Certain  Spinal  Analgesics;  Based  on  Two  Thousand 
Administrations,"  Trans.  Am.  Ther.  Soc,   1910,  57. 


SPINAL    ANALGESIA    AND     SPINAL    ANESTHESIA        569 

analgesia.  The  rate  of  diffusion  of  the  lighter  fluid  is  controlled  by  the 
addition  of  a  larger  or  smaller  percentage  of  alcohol.  Babcock  holds  that 
the  analgesic  drug  is  decomposed  by  the  cerebrospinal  fluid,  which  still 
further  limits  its  field  of  activity.  The  less  the  alcohol  used,  the  more 
rapid,  is  this  decomposition;  hence,  as  the  fluid  diffuses,  it  decomposes, 
and  the  anesthetic  effect  can  be  limited  very  largely  to  any  desired  por- 
tion of  the  spinal  canal. 

Tufiier,^  considered  the  analgesic  action  of  the  agent  to  be  local, 
whether  it  be  exerted  upon  the  cord,  the  nerve  roots,  or  the  spinal 
ganglion,  being  not  determined.  He  inclined  to  the  belief,  however, 
that  it  is  confined  exclusively  to  the  nerve  roots.  The  early  symptoms, 
such  as  malaise  and  trembling,  he  attributed  to  the  direct  action  of  the 
anesthetic  agent  upon  the  spinal  axis. 

Spiller  and  Leopold  ^  experimented  with  stovain  in  an  effort  to  de- 
termine certain  points  with  reference  to  the  action  of  this  agent  upon  the 
nervous  system.  They  thought  that  perhaps  stovain,  which  produces 
temporary  anesthesia,  might,  by  repeated  injections,  produce  anesthesia 
of  gradually  increasing  duration  until  a  finally  persisting  loss  of  sensa- 
tion, resulting  from  organic  change,  might  ensue.  They  desired  to 
ascertain  whether  a  systemic  degeneration  of  the  posterior  roots  and 
their  continuation  in  the  posterior  columns  of  the  cord  is  the  common 
result  of  the  repeated  use  of  stovain.  They  also  desired  to  determine 
whether  the  paralysis  that  occurs  in  stovain  anesthesia  is  of  a  motor 
or  sensory  type,  i.  e.,  whether  it  is  produced  by  changes  in  the  peripheral 
motor  neurons,  or  is  the  result  of  ablation  of  all  afferent  impulses  which 
normally  pass  over  the  posterior  roots.  They  called  attention  to  the  fact 
that  reflex  action  and  all  recognition  of  toxicity  of  the  limbs,  and  neces- 
sarily of  the  position  of  the  limbs,  are  lost  if  all  peripheral  afferent  im- 
pulses are  cut  off. 

In  order  to  satisfy  themselves  upon  these  points  with  reference  to 
stovain,  Spiller  and  Leopold  experimented  upon  dogs,  5  subjects  being 
employed.  They  performed  lumbar  puncture,  using  stovain  in  doses  of 
0.05  gm.  to  2  gm.,  the  injections  being  usually  at  intervals  of  2  or  3  days. 

They  divided  the  symptoms  into  temporary  and  permanent.  The 
temporary  symptoms  consisted  of  flaccid  paralysis  and  complete  or  par- 
tial sensory  loss.  The  permanent  symptoms  consisted  of  ataxia,  de- 
creased sensation,  and,  in  one  case,  loss  of  patellar  reflex.  The  symp- 
toms became  permanent  after  the  third  injection,  remaining  until  the 
end  of  the  experiment. 

These  investigators  considered  that  their  experiments  clearly  demon- 
strated that  stovain  affects  especially  the  anterior  and  posterior  roots  of 

^Tuffier:      Op.  cit.,  La  Presse  medicale,  June  8,  1901. 

*  Spiller  and  Leopold :      ' '  The  Effects  of   Stovain  on  the   jSTervous   System, ' ' 
/.  Am.  Med.  Assn.,  June  4,  1910,  1840. 


570  ANESTHESIA 

the  cord.  The  degeneration  of  the  posterior  root  fibers  was  intense,  as 
was  likewise  that  of  the  intramedullary  portion  of  the  lumbar  and  sacral 
posterior  root  fibers  in  the  thoracic  region.  The  posterior  thoracic  roots 
were  unaifected.  Stovain  evidently  causes  slight  degeneration  in  the 
periphery  of  the  anterolateral  columnS;,  but  has  less  effect  here  than  on 
the  nerve  roots. 

The  lesions  obtained  by  them  could  not  have  been  produced,  they 
hold,  by  the  trauma  of  the  needle,  as  the  sections  of  the  lumbar  region 
examined  were  i/^  to  2  inches  above  the  point  of  injection,  and  yet  the 
posterior  and  anterior  roots  were  greatly  degenerated. 

'Tt  would  be  unwarranted,"  they  conclude,  "to  apply  these  findings 
too  strictly  to  man,  as  no  grave  changes  have  been  found  as  yet  in  the 
human  cord.  At  most,  our  findings  would  shov/  that  repeated  injec- 
tions of  stovain  might  be  injurious,  and  would  make  one  cautious  in  em- 
ploying several  injections  within  a  short  time  in  the  same  subject." 

Spielmeyer  ^  examined  human  spinal  cords  in  his  study  of  the  pathc 
logico-anatomical  considerations  involved  in  spinal  analgesia.  He  ex- 
amined the  central  nervous  system  of  13  patients  who  had  died  from 
various  causes  within  from  2  to  8  days  after  spinal  analgesia  with  sto- 
vain. In  all  except  1  case  death  was  in  no  way  related  to  the  spinal 
analgesia.  In  1  case  death  was  due  to  respiratory  paralysis  40  hours 
^fter  the  operation. 

Upon  examination  of  the  woman  who  died  from  respiratory  paraly- 
sis advanced  changes  in  the  cells  of  the  spinal  cord  were  found.  Spiel- 
meyer did  not  regard  these  as  a  direct  effect  of  the  analgesic  agent,  simi- 
lar changes  having  been  found  in  other  cases  in  which  death  was  due  to 
respiratory  paralysis  of  different  origin.  In  three  other  cases  Spiel- 
meyer was  enabled  to  demonstrate  characteristic  changes  in  the 
polygonal  motor  cells  of  the  cord.  The  cells  of  the  posterior  horn  and 
the  spinal  ganglia  presented  no  changes.  Spielmeyer  was  able  to  pro- 
duce, experimentally,  similar  changes  in  the  motor  ganglion  cells  of 
dogs  and  monkeys. 

Michelsson  holds  the  view  that,  as  this  histological  picture  exactly 
corresponds  to  the  phenomena  which  usually  follow  upon  the  destruction 
of  the  axis  cylinder,  it  must  be  left  undecided  whether  a  primary  or 
secondary  effect  of  stovain  upon  the  ganglia  is  responsible,  although 
animal  experiments  rather  favor  the  first  assumption.  It  is  certainly 
remarkable,  he  says,  that  these  changes  can  be  observed  only  on  the  mo- 
tor ganglion  cells,  high  up  in  the  cervical  cord,  and  that  there  is  always 
a  predominating  num.ber  of  normal  polygonal  cells,  besides  the  affected 
cells.    This  probably  accounts  for  the  fact  that  motor  disturbances  were 

^  Spielmeyer :  ' '  Pseudosystemer-krankungen  des  Eiiekeimiarkes  nach  sto- 
vainanasthesie, "  Neurol.  Centrlbl,  Jan.  16,  1909,  69;  see,  also,  Miinch.  med. 
Woch.,  Aug.  4,  1908,  1629. 


SPINAL    ANALGESIA    AND    SPINAL    ANESTHESIA        571 

not  noted  in  any  of  Spielmeyer's  cases  in  man  or  in  animals.  In  the 
13  cases  Spielmeyer  employed  stovain  in  doses  of  0.12  gm.  Patients 
who  had  received  the  customary  dose  of  0.05  gm.  to  0.07  gm.  presented 
no  changes  in  the  central  nervous  system,  so  that  the  assumption  would 
seem  to  be  justified  that  this  stovain  dose  as  a  rule  does  not  produce 
any  lesions  of  the  ganglion  cells. 

Klose  and  Vogt  ^  employed  tropococain  and  novocain  in  a  series  of 
experiments,  which  led  them  to  the  same  results  as  those  obtained  by 
Spielmeyer  with  stovain. 

These  investigators  found  that  the  injected  agents  are  distributed 
over  the  entire  space  occupied  by  the  cerebrospinal  fluid  within  half 
an  hour  at  the  latest.  The  specific  gravity  of  the  solution,  and  the  posi- 
tion of  the  animal,  are  of  subordinate  importance.  The  alkaloids  re- 
main for  a  disproportionately  long  time  in  the  cerebrospinal  fluid. 
Among  the  agents  examined  by  them,  tropococain  persisted  for  relatively 
the  shortest  time,  stovain  for  the  longest,  novocain  ranking  midway 
between.  In  this  scale  of  excretion  the  duration  of  the  absorption,  the  so- 
journ in  the  blood,  and  the  duration  of  the  analgesia  stand  in  direct 
proportion  to  the  time  after  which  absorption  begins. 

Following  the  work  of  Klose  and  Vogt,  Barker  ^  conducted  a  series 
of  experiments  to  determine  how  long  stovain  remains  in  the  dural  sac 
after  injection,  unabsorbed,  fixed,  or  destroyed;  what  effects,  apart  from 
analgesia,  the  agent  produces;  what  immediate  and  remote  effects,  if 
any,  the  drug  has  upon  the  structures  with  which  it  comes  in  contact; 
and  how  the  agent  is  eliminated  from  the  system  generally.  Attention 
is  directed  by  him  to  the  importance  of  determining  these  points  with 
reference  to  the  various  analgesic  compounds  or  agents  before  this 
method  of  inducing  analgesia  can  be  put  in  its  proper  place  among  sur- 
gical procedures. 

In  nine  of  his  cases  previously  injected  with  stovain  Barker  with- 
drew the  cerebrospinal  fluid,  for  various  reasons,  at  periods  varying 
from  half  an  hour  to  forty-six  hours  after  injection.  Stovain  was  found 
to  be  present  in  six  cases,  the  time  after  injection  ranging  from  one-half 
hour  to  twenty-four  hours;  negative  in  one  case  at  forty-four  hours; 
and  doubtful  in  two  at  forty-five  and  forty-six  hours  respectively. 

The  question  whether  any  immediate  effect  is  produced  upon  the 
structures  within  the  dura  by  the  stovain  injection  was  answered,  in 
Barker's  experience,  in  the  affirmative.  In  all  the  cases  in  which  he 
withdrew  cerebrospinal  fluid  within  46  hours  of  the  injection  of  stovain 

^  Klose  and  Vogt :  ' '  Physiologisclie  imd  anatomische  Untersuchungen  zur 
Lumbalanasthesie  und  zur  Frage  ihrer  klinischen  Verwertharkeit, "  Miinch.  med. 
Woch.,  March  9,   1909. 

-  Barker :  '  *  Elimination  of  Stovain  After  Spinal  Analgesia, ' '  Brit.  Med.  J., 
Sept.  18,  1909,  789. 


572  ANESTHESIA 

into  it  the  fluid  was  distinctly  turbid.  The  turbidity  was  found  on 
microscopical  examination  to  be  due  to  the  presence  of  leukocytes  of 
various  forms.  The  theory  that  the  headache  which  sometimes  follows 
spinal  analgesia  is  due  to  aseptic  irritation  and  hypersecretion  within 
the  dura  did  not  seem  to  Barker  quite  satisfactory. 

Barker  fouiid  from  the  study  of  his  cases  that,  long  after  the  anal- 
gesic effect  of  the  drug  has  passed  off,  stovain  or  its  base  can  be  shown 
to  be  unmistakably  present  in  the  cerebrospinal  fluid.  No  satisfactory 
answer  could  be  given  to  the  question,  Why  does  the  analgesia  last  for 
only  a  couple  of  hours?  He  suggested  that  only  perfect  stovain  is 
analgesic,  and  that  its  base  split  off  by  the  alkaline  cerebrospinal  fluid 
is  not,  and  that  this  base  is  what  is  recovered  in  subsequent  tappings. 

From  his  clinical  studies  he  thought  it  clear  that  no  permanent 
structural  change  in  the  nervous  structures  leading  to  definite  symp- 
toms has  been  proved  to  be  due  to  the  injections. 

From  the  foregoing  references  to  the  experimental  work  of  various 
investigators  it  will  be  noted  that  the  physiological  action  of  cocain  and 
other  analgesic  agents  when  injected  into  the  subarachnoid  space  was 
not  clearly  understood  in  the  earlier  stages  of  the  development  of  spinal 
analgesia,  and  that  the  studies  of  later  investigators  have  not  served 
to  fully  settle  these  problems. 


COURSE,  EXTENT,  AND  DURATION  OF  ANALGESIA 

Course. — The  course  of  the  analgesia,  or  the  sequence  in  which  the 
various  parts  of  the  body  are  affected,  varies  with  the  individual,  the 
point  of  injection,  the  agent  employed,  and  the  technique. 

As  a  rule,  in  lumbar  analgesia,  after  a  minute  or  so,  sensibility  to 
pain  is  lessened  in  the  perineum,  external  genital  organs,  and  the  inner 
side  of  the  thigh.  The  first  reflex  to  disappear  is  the  patellar,  which  is 
quickly  followed  by  the  disappearance  of  ankle  clonus.  Loss  of  sensi- 
bility to  pain  follows,  in  the  order  named,  in  the  posterior  surface  of  the 
thighs  and  legs,  the  soles  of  the  feet,  and  the  anterior  surface  of  the 
legs,  and  the  thighs  up  to  Poupart's  ligament.  The  analgesia  then 
gradually  extends  to  the  umbilical  region,  and  from  that  zone  on,  in 
some  instances,  higher  and  higher,  until  universal  analgesia,  as  this 
may  be  determined  from  superficial  tests,  supervenes.  In  some  in- 
stances this  includes  the  mucous  membranes  of  the  mouth,  nose,  and 
larynx. 

The  course  of  the  disappearance  of  sensibility  to  pain  is  segmental, 
proceeding  from  the  fourth  or  fifth  sacral,  segment  by  segment,  to  what- 
ever limit  it  reaches  in  the  individual  case. 

Extent. — Analgesia  may  be  partial  or  complete,  with  reference  to 


Fig.  235. — Operation  Under  Way  for  Removal  of  Tumor  of  Abdominal  Wall  Under 
Spinal  Analgesia.     Ten  minutes  after  puncture.      Face  screen  in  position. 


Fig.  236. — Second  Operation,  Same  Analgesia,  Same  Patient  as  in  Figure  235. 
Exsection  of  varicose  veins,  both  legs;  patient  reading,  resting  paper  against  face 
screen. 


574 


ANESTHESIA 


the  extent  of  the  body  involved,  as  well  as  to  the  degree  to  which  sensa- 
tion is  abolished.  The  term  complete  is  generally  employed  to  signify 
the  degree  of  loss  of  sensation,  particularly  pain  sense,  though  the 
word  is  not  infrequently  used  with  reference  to  the  extension  of  the 
analgesia  over  the  entire  body.  For  the  latter  purpose  the  word 
universal  is  perhaps  preferable.  When  the  cerebral  cortex  becomes 
involved,  the  analgesia  merges  into  true  anesthesia,  during  which 
the  patient  loses  consciousness,  or  lapses  into  a  deep  sleep  with 
snoring. 

In  the  majority  of  instances  in  which  the  analgesic  agent  is  injected 


Fig.  237. — Same  Patient  as  in  Figures  235  and  236.  At  End  of  Operation.  While  the 
wounds  are  being  sutured,  She  drinks  a  cup  of  tea;  facial  expression  shows  absence  of 
pain  or  discomfort. 


into  the  lumbar  or  lower  dorsal  region  the  analgesia  extends  to  the  um- 
bilical region.  Under  different  circumstances  the  height  to  which  this 
goes  varies,  as  previously  noted. 

It  not  infrequently  happens  that  complete  analgesia  to  a  very  high 
level,  or  even  universal  analgesia,  follows  the  introduction  of  moderate 
doses  of  the  analgesic  agent  into  the  lumbar  region. 

Morton,^  in  1903,  published  a  record  of  929  cases  operated  upon  be- 
low the  diaphragm  and  76  above  it.  In  one  case  he  removed  the  entire 
superior  maxilla  for  carcinoma,  the  analgesia  being  complete.  He  intro- 
duced in  this  case  half  a  grain  of  cocain  between  the  third  and  fourth 
lumbar  vertebrae. 

^Morton:  "Excision  of  the  Superior  Maxillary  Under  Medullary  Narcosis, " 
Am.  Med.,  March  21,  1903,  451. 


SPINAL    ANALGESIA     AND     SPINAL    AN1^:STHESIA        575 

Chaput  ^  noted  that  in  53  of  102  cases  the  analgesia  exiended  ahove 
the  diaphragm,  the  arms  being  involved  in  31,  the  face  in  13;  while 
in  9  cases  the  analgesia  of  the  head  was  complete.  'J'his  high  analgesia 
was  obtained  by  the  rapid  and  forcible  injection  of  large  doses  of  cocain. 

Pedeprade  ^  noted  5  cases  in  which  analgesia  was  complete  through- 
out the  body. 

Tuffier  ^  reported  the  removal  of  a  cyst  of  the  lung  under  medullary 
analgesia. 

In  4  of  the  writer's  early  cases  the  analgesia  extended  over  the  entire 
body,  even  the  mucous  membrane  of  the  mouth  and  larynx  being  com- 


FiG.    238.— Enlarged    Picture    of    Patient's    Face    Showing    Facial    Expression. 


pletely  analgesic,  as  recorded  m  a  personal  letter  to  Patterson  and  in- 
corporated by  the  latter  in  his  admirable  resume  of  the  literature  of 
spinal  analgesia.*  In  27  other  cases,  operated  upon  under  lumbar  anal- 
gesia, with  moderate  doses,  the  analgesia  was  sufficiently  extensive  to 
have  rendered  painless  operation  upon  the  upper  part  of  the  body. 

A  typical  instance  of  universal  analgesia  °  was  that  of  a  female  pa- 
tient, aged  11^^  years,  who  was  suffering  from  tuberculous  abscesses  of 
the  foot,  with  tarsal  necrosis.  On  February  7,  1901,  she  was  operated 
upon  under  cocain  spinal  analgesia.     The  injection  was  made  between 

1  Chaput :  ' '  Sur  la  Cocaine  Lombaire, ' '  Bull,  et  Mem.  d.  I.  Soc.  d.  CMr.  de 
Paris,  1901,  883. 

2  Pedeprade :  "L'Analgesie  par  injection  de  cocaine  sous  1 'arachiioi'de  lom- 
baire en  chirurgie. "     Paris,  1901. 

3  Tuffier:      Op.  cit.,  La  Presse  med.,  June  8,   1901. 

^Patterson:  "Spinal  Analgesia.  The  Present  Status  of  the  Method  Based  on 
a  Review  of  the  Literature,"  ArcMv  Internal,   d.  CMr.,  1,  502;   £,  53. 

^Bainbridge:  "A  Report  of  Twenty-four  Operations  Performed  During 
Spinal  Analgesia,"  Med.  News,   May  4,  1901,  Case  IX. 


576  ANESTHESIA 

the  third  and  fourth  lumbar  vertebrse,  the  amount  of  cocain  being  15 
minims  of  a  two  per  cent  solution.  Analgesia  extended  to  the  level  of 
the  diaphragm  in  2  minutes.  The  operation  lasted  20  minutes,  and  in- 
cluded the  opening  of  the  abscesses  and  the  removing  of  carious  bone 
and  tuberculous  tissue.  At  the  close  of  the  operation,  25  minutes  after 
the  injection,  there  was  absolute  absence  of  pain  sense  over  the  entire 
body.  Tests  proved  that  the  analgesia  was  present  in  the  conjunctiva, 
the  mouth,  on  the  tongue,  and  over  the  posterior  pharyngeal  wall. 

A  similar  instance  of  complete  analgesia  occurred  in  a  child  five  years 
of  age,^  upon  whom  circumcision  was  performed.  Other  cases  of  anal- 
gesia extending  practically  over  the  entire  body  are  cited. ^  In  one  case 
(No.  XXII)  a  tuberculous  sinus  extending  into  the  external  condyle 
of  left  humerus  was  enlarged  and  dead  bone  removed.  In  another  (ISTo. 
XXIV)  the  left  thumb  was  amputated  at  the  lower  third  of  the  meta- 
carpal bone.  In  the  former  case  8  minims  of  a  two  per  cent  solution  of 
cocain  were  injected  between  the  third  and  fourth  lumbar  vertebrse;  in 
the  latter  32  minims  of  a  two  per  cent  solution  were  injected  between 
the  second  and  third  lumbar. 

In  a  number  of  recorded  instances  the  analgesia  was  unilateral,  pre- 
sumably, according  to  Donitz,^  because  the  injection  was  made  at  the 
beginning  of  the  eauda  equina,  in  the  right  or  left  group  of  nerve  fibers, 
instead  of  the  cisterna  terminalis.  Dift'usion  is  thus  incomplete,  the  so- 
lution reaching  only  the  contiguous  nerve  roots,  hence  producing  only 
partial  analgesia,  or  analgesia  of  a  given  side. 

Duration. — The  duration  of  analgesia  induced  by  subarachnoid  in- 
jection is  generally  from  %  of  an  hour  to  1^2  hours,  with  cocain,  sto- 
vain,  and  tropococain,  the  last  named  being  shorter  than  the  other  two, 
and  from  21^  to  3  hours,  with  novocain  and  adrenalin.  Instances  have 
been  recorded  where  the  analgesia  lasted  from  17  minutes  to  8  hours. 
Jonnesco  states  that  with  his  method  analgesia  lasts  from  1^/2  to  2 
hours. 

The  writer  has  found  the  analgesia  to  vary  in  duration  from  45 
minutes  to  3  hours  and  20  minutes.  This  has  reference  to  the  complete 
return  of  pain  sense.  During  the  early  days,  when  the  dosage  was  so 
uncertain,  when  cocain  was  used  exclusively,  and  when  so  much  was 
being  said  concerning  the  dangers  of  this  agent,  very  conservative  doses 
were  employed,  and  the  analgesia  was  often  of  shorter  duration  than 
obtains  at  the  present  time,  when  the  method  is  more  thoroughly  under- 
stood in  all  its  phases.  It  may  be  said,  however,  that,  with  all  the  added 
knowledge  gained  from  experience,  the  duration  of  analgesia  is   still 

'  Bainbridge :  "Eeport  of  Twelve  Operations  on  Infants  and  Young  Chil- 
dren During  Spinal  Analgesia,"  Archives  of  Pediat..  July,   1901,  Case  I. 

=  Bainbridge:     Op.  cit.,  Med.  Neivs,  May  4,  1901,  Cases  XV,  XXII  and  XXIV. 
•JDonitz:      Verh.  d.  deutsch.  Gesell.  f.  Chir.,  1905,  536. 


SPINAL    ANALGESIA    AND    SPINAL    ANF^STHESIA        577 

problematical,  and  will  doubtless  continue  to  be  so  until  some  delinite 
scientific  basis  for  dosage  is  formulated. 


ACCOMPANYING    PHENOMENA 

Subjective. — The  manifestation  of  subjective  symptoms  begins 
within  from  two  to  eight  minutes  after  the  injection  is  made,  varying 
with  different  patients.  As  a  rule,  the  first  subjective  symptom  noted  is 
a  tingling  sensation  and  numbness  in  the  feet  and  sometimerj  in  the  legs. 
During  the  first  ten  minutes  or  so  there  is  a  sense  of  malaise,  charac- 
terized by  a  feeling  of  epigastric  heaviness,  thirst,  and  air-hunger.  A 
sensation  of  cold,  or  of  heat,  with  sweating,  and  sometimes  salivation, 
follow  the  vasomotor  reaction  to  the  analgesic  agent.  In  a  certain  pro- 
portion of  cases  there  is  a  trembling  of  the  legs  amounting  to  clonic 
contractions.     There  may  be  cramps  in  the  muscles  of  the  legs. 

Nausea  occurs  in  about  thirty  per  cent  of  cases,  as  culled  from  the 
literature  by  Patterson.^  It  seems  to  bear  no  relation  to  the  preceding 
meal.  The  size  of  the  dose  of  the  analgesic  agent  injected  bears  a  rela- 
tion to  the  nausea,  the  larger  the  dose  the  more  certain  the  nausea. 
The  bulk  or  volume,  rather  than  the  strength,  of  the  injected  fluid  is 
held  by  Gray  and  others  to  be  the  main  factor  in  the  production  of 
nausea. 

Vomiting,  which  occurs  in  about  forty  per  cent  of  cases,  begins,  as 
a  rule,  in  from  five  to  ten  minutes  after  the  injection,  sometimes  earlier. 
It  occurs  in  women  more  frequently  than  in  men.  It  is  seldom  re- 
peated more  than  3  or  4  times.  There  may  be  late  vomiting,  coming  on 
in  from  2  to  3  hours  after  operation,  and  continuing  for  3  or  3  days, 
according  to  some  writers.  Personal  experience,  and  that  of  all  but  a 
few  operators,  is  at  variance  with  this  observation. 

An  interesting  study  of  the  subjective  symptoms  has  been  furnished 
by  Fraicou,-  who  operated  upon  himself  for  hernia  under  spinal  anal- 
gesia with  strychninized  stovain. 

The  injection  was  made  by  an  assistant,  between  the  twelfth  dorsal 
and  first  lumbar  vertebrae,  1  c.  c.  of  water,  containing  5  centigrams  of 
stovain  and  1  milligram  of  strychnin,  being  employed.  In  addition  to 
this,  2  centigrams  of  stovain  were  employed  locally  in  the  iliac  fossa 
and  external  portion  of  the  inguinal  region. 

During  the  entire  operation,  which  was  performed  without  assist- 
ance, the  analgesia  was  complete  below  the  anterior  superior  iliac  spines. 
The  body  above  this  level  remained  unaffected  throughout.     The  anal- 

^  Patterson:     Op.  cit. 

2  Fraicou :  ' '  Auto-observation  d  'une  auto-operation  de  hernie  sous  la  rachi- 
strychno-stovainizatiou, "  La  Presse  med.,  Feb.   11,   1911,   105. 


578 


ANESTHESIA 


gesia  disappeared  as  the  work  was  drawing  to  a  close,  and  the  suture 
of  the  skin  was  slightly  painful. 

The  conclusions  formulated  from  this  experience  are  in  part  as  fol- 
lows: (1)  The  pain  produced  by  the  spinal  puncture  is  greater  than 
that  caused  by -a  simple  subcutaneous  injection  with  the  Pravaz  syringe. 
The  pain,  however,  is  less  disagreeable  than  the  sensations  experienced 
by  the  majority  of  patients  at  the  beginning  of  chloroform  anesthesia. 

(2)  The  anesthesia  became  established  with  pleasant  sensations,  and 
disappeared  imperceptibly. 


Fig.  239. — Amputation  of  Foot  Just  Above  Ankle  Joint  Under  Spinal  Analgesia. 
Operator  with  clamp  grasping  sensory  nerve  and  cutting  it  short;  note  absence  of 
pain  in  expression. 


(3)  The  mild  excitement  at  the  beginning  of  the  anesthesia,  and 
the  vertigo  which  was  felt  on  making  sudden  movements,  are  proof  of 
the  anesthetic  fluid  having  slightly  spread  toward  the  cerebral 
liemispheres.  The  intellectual  faculties  remained  absolutely  intact,  and 
consciousness  was  entirely  preserved.  This  is  conclusively  proven  by  the 
fact  that  the  surgeon  also  conducted  a  delicate  operation  upon  himself 
to  a  successful  outcome. 

(4)  The  technique  of  the  anesthetic  method  and  the  patient's 
position  after  the  injection  are  the  essential  factors  on  which  depend 
the  degree  and  intensity  of  the  anesthesia. 

(5)  The  anesthesia  has  a  great  tendency  to  remain  segmental. 

(6)  The  harmlessness  of  the  method  of  rachi-strychno-stovainiza- 


Fig.  240. — Inguinal  Hernia,  Inherent  Intestine,  Adhesions  Being  Pulled  Apart 
Under  Spinal  Analgesia.     Babcock's  diffusible  solution.     Head  lowered. 


Fig.  241. — Same  as  Figure  240,  Head  Elevated.     Patient  reads  to  surgeons  during 

operation. 


580 


ANESTHESIA 


tion  is  illustrated  by  the  fact  that  during  the  entire  anesthesia  no  un- 
pleasant incident  or  phenomenon  occurred,  aside  from  vertigo  caused 
by  all  sudden  movements,  despite  the  sitting  position  which  it  was 
necessary,  for  the  operator  to  maintain  throughout. 

(7)  The  contrast  between  the  absence  of  any  accident  during  the 
anesthesia  and  the  onset  of  transitory  postoperative  and  postanesthetic 
symptoms  is  accounted  for  by  the  fashion  in  which  the  operation  was 
performed.     Although  in  the  upright  position,  and  although  the  move- 


FiG.  242. — Same  Patient  at  End  of  Operation.     Patient  drinking  water. 


ments  during  the  operation  had  no  influence  upon  the  onset  of  imme- 
diate symptoms,  they  gave  rise  at  least  to  secondary  disturbances. 

Another  instance  of  auto-observation  of  the  symptoms  caused  by 
spinal  analgesia  was  the  operation  for  appendicitis  recently  performed 
upon  himself  by  Dr.  Bertram  F.  Alden,  chief  surgeon  to  the  French 
Hospital,  San  Francisco. 

The  following  history  embraces  the  auto-observations  of  a  patient 
operated  upon  by  the  author : 

Miss  E.  F.,  47  years  of  age,  trained  nurse.  According  to  her  own 
statement,  she  had  had  chronic  nephritis  for  a  number  of  years,  with 
albumin  as  high  as  25  per  cent  by  volume  at  times,  with  hyaline, 
granular  and  blood  casts,  crystals  of  triple  phosphate,  and  kidney  and 
bladder  epithelia.  This  statement  was  verified  by  urinalysis  previous  to 
operation.  For  35  years  she  had  had  goiter,  which  was  found  to  be  of 
the  cystic  variety.    The  goiter  developed  with  puberty,  since  which  time 


SPINAL    ANALGESIA    AND     SPINAL    ANESTHESIA        581 

she  had  always  been  extremely  nervous,  with  more  or  less  functional 
irregularity  of  the  heart.  Eeferred  to  me,  January  5,  1911,  })y  Dr.  E.  M. 
Mosher,  of  Brooklyn,  for  multiple  uterine  fibroids  which  filled  the  entire 
pelvis.  On  January  11  panhysterectomy  and  appendectomy  were  per- 
formed under  spinal  analgesia,  one-half  dram  of  a  3  per  cent  solution  of 
stovain  being  injected  between  the  second  and  third  lumbar  vertebrae. 

The  patient's  description  of  her  experience  follows:  "In  a  few  min- 
utes (5)  after  the  injection  the  lower  extremities  became  lifeless.  Just 
as  the  incision  was  made  into  the  skin  of  the  abdomen  my  head  was 
raised  in  order  to  put  a  pillow  under  it.  I  saw  the  incision,  and  felt  the 
doctors  working,  but  experienced  absolutely  no  pain  until  the  last  3 
stitches  were  applied.  These  caused  slight  pain.  By  this  time  the  anal- 
gesia was  gradually  disappearing.  I  slept  at  short  intervals  during  the 
operation.  I  was  given  during  the  operation  by  hypodermic  injection 
1/100  gr.  nitroglycerin  and  1/6  gr.  morphin,  and  at  intervals  small 
quantities  of  brandy  and  water  by  mouth.  After  the  operation  I  drank 
lemonade  to  the  health  of  the  doctors.  I  was  removed  to  my  room  per- 
fectly conscious  and  free  from  pain.  I  had  no  unjDleasant  after-effects 
from  the  analgesia.     The  wound  healed  by  primary  union." 

On  February  11,  1911,  half  of  the  cystic  thyroid  gland  was  removed 
under  local  cocain  analgesia.  Since  that  time  the  patient  has  been  per- 
fectly Avell,  resuming  her  work  as  a  professional  nurse. 

Objective. — Tests  elicit  the  fact  that  the  sense  of  pain  is  the  first  to 
disappear,  while  the  senses  of  touch  and  posture  are  gradually  lost  to  a 
greater  or  less  extent,  according  to  dosage.  Motor  j)areses  manifest 
themselves  first  in  the  muscles  of  the  feet,  gradually  extending  upward. 
The  extensors  are  more  pronouncedly  involved  than  are  the  flexors. 

From  Patterson's  ^  investigation  of  the  subject,  it  appears  that  in 
about  30  per  cent  of  the  cases  there  is  incontinence  of  feces,  due  to  the 
direct  insensibility  of  the  rectum.  In  about  10  per  cent  of  the  cases 
there  are  urethrovesical  symptoms.  In  all  cases  the  sense  of  distention, 
as  well  as  of  contact,  with  reference  to  the  bladder  is  lost. 

Pallor  of  the  face  and  profuse  perspiration  are  sometimes  noted. 

The  general  observation  seems  to  be  that  there  is  a  fall  of  blood 
pressure  following  immediately  upon  the  injection,  and  that  this  varies 
with  the  completeness  of  the  analgesia  and  "with  the  parts  affected.  The 
pulse  rate  varies  from  80  to  129  beats  per  minute,  but  the  cardiac 
rhythm  is  regular. 

Babcock  ^  holds  that  surgical  shock  is  less  apt  to  occur  with  spinal 
analgesia  than  with  general  anesthesia,  because  of  the  blocking  off  of  the 
nerves  of  sensation  in  the  former.     "The  shock  of  the  later  stages  of 

^  Patterson :     Op.   cit. 

^Babcock:      "Spinal  Anesthesia,  a   Clinical   Study   of   658   Administrations," 
Penn.  Med.  J.,  Aug.,  1909. 


582  ANESTHESIA 

the  operation,"  he  says,  "is  negatived  by  the  emergence  of  the  spinal 
centers  from  the  depression  of  the  anesthetic.  For  this  reason,  under 
spinal  anesthesia  it  is  not  unusual  to  find  the  pulse  stronger  and  fuller 
and  the  patient  in  better  general  condition  at  the  end  of  an  operation 
than  at  the  beginning." 

In  low  analgesia  the  effect  upon  the  respiration  is  shown  in  a  greater 
or  less  increase  in  rapidity,  while  the  rhythm  is  practically  unchanged. 
The  greatest  danger  of  so-called  high  analgesia  is  paralysis  of  the  mus- 
cles concerned  in  respiration.  This  may  vary  from  slight  and  temporary 
respiratory  embarrassment  to  complete  and  lasting  respiratory  paralysis. 

Jonnesco  ^  holds  that  such  phenomena  as  pallor,  nausea,  and  sweating 
rarely  occur  when  the  stovain-strychnin  solution  recommended  by  him  is 
used.  The  face,  in  such  cases,  retains  its  normal  aspect;  nausea  occurs 
in  2.25  per  cent,  vomiting  in  1.25  per  cent,  and  sweating  in  2  per  cent. 
He  has  noticed  fecal  incontinence  in  4  per  cent  of  cases  in  cachectic, 
feeble  individuals.  The  pulse,  which  is  slowed  by  stovain  alone,  is  usu- 
ally normal  in  rapidity  and  strength  when  the  stovain-strychnin  solution 
is  employed.  Sometimes,  according  to  Jonnesco,  it  rises  to  80  or  90, 
but  always  remains  strong.  The  5  cases  in  which  he  noted  temporary 
stoppage  of  respiration  were  cases  in  which  he  departed  from  his  usual 
method  in  some  detail.  The  addition  of  the  strychnin  is  claimed  by  him 
to  obviate  this  difliculty. 


POSTOPERATIVE    PHENOMENA 

Alessandri  ^  contributes  a  compilation,  from  the  Neuro-pathological 
Institute  in  Eome,  of  the  unfavorable  accidents  and  complications  fol- 
lowing spinal  analgesia  with  stovain  injections. 

The  nervous  system,  according  to  this  observer,  which  has  a  great 
affinity  for  stovain,  presents  chromatolysis  of  the  nerve  cells,  which  may 
affect  all  parts,  inclusive  of  the  bulb.  In  this  way  paresis  of  all  descrip- 
tions may  follow.  Nausea  and  vomiting  are  not  uncommon,  as  the  im- 
mediate result  of  the  effect  upon  the  bulb.  Syncope  and  severe  respira- 
tory disturbance  are  equally  frequent. 

Among  the  remote  results  of  stovain  analgesia  mentioned  by  Ales- 
sandri are:  Hyperthermia,  up  to  40°  C,  lasting  several  days,  referred 
by  some  observers  to  shock  due  to  operation;  disturbance  of  the  sensory 
nerves,  represented  by  headache,  and  pains  of  the  spinal  nerves ;  trophic 
disturbances  in  the  form  of  bed  sores;  psychic  disturbances  in  the  form 
of  delirium  and  persistent  insomnia. 

^Jonnesco:      Op.  cit.,  Brit.  Med.  J.,  Nov.   13,  1909,   1396. 

^  Alessandri :  ' '  Gli  accidenti  nervosi  rachianestesia, ' '  II  Morgagni,  Aug.  24, 
1909. 


SPINAL    ANALGESIA    AND    SPINAL    ANESTHESIA        583 

Attention  is  called  to  the  fact  that  certain  disturbances  which  have 
been  attributed  to  the  stovain  may  also  be  referable  to  faulty  puncture  of 
the  medullary  canal  or  puncture  at  an  unsuitable  spot. 

Intense  headache,  dizziness,  nausea,  vomiting,  rigidity  of  the  neck, 
tenderness  to  pressure  over  the  cervical  vertebrae,  and  pain  in  the  small 
of  the  back  constitute  a  symptom-complex  known  as  meningism — due 
to  irritation  of  the  meninges. 

Sleeplessness,  lasting  sometimes  for  as  long  as  7  nights,  has  been  re- 
ported as  following  subarachnoid  analgesia. 

Postoperative  fever,  with  or  without  chills,  the  temperature  some- 
times running  as  high  as  102°  F.,  in  some  instances  follows  the  injec- 
tion of  tropococain,  the  fever  being  a  manifestation  of  irritation  of  the 
heat  center  of  the  brain. 

Headache,  retention  of  nrine,  and  rise  of  temperature  are  seldom 
noted,  according  to  Jonnesco,  when  his  method  is  employed,  and  when 
they  do  occur  they  are  of  short  duration.  He  has  observed  headache  in 
6.25  per  cent  of  cases,  but  it  is  not  severe,  and  disappears  in  a  few  hours 
after  operation.  Transitory  retention  of  urine  was  observed  in  4.5  per 
cent  of  cases.  In  no  case  did  the  temperature  reach  104°  F.  Post- 
operative vomiting  has  rarely  been  observed  by  him,  and  he  has  never 
seen  postoperative  analgesia  paralysis. 

Hoseman,^  in  discussing  the  after-effects  of  lumbar  analgesia  and 
their  control,  calls  attention  to  the  importance  of  measuring  lumbar 
pressure.  This  serves  to  show  that  headache  as  a  sequel  to  lumbar  anal- 
gesia is  always  associated  with  changes  of  pressure,  which  is  rarely  in- 
creased, but  frequently  diminished.  Where  the  pressure  is  increased  the 
headache  is  favorably  affected  by  the  withdrawal  of  spinal  fluid;  when 
it  is  decreased,  the  introduction  of  fluid  in  the  form  of  subcutaneous  salt 
infusion  and  enemata  is  serviceable.  The  introduction  of  these  meas- 
ures in  the  Eostock  Surgical  Clinic  obviated  the  severe  after-effects  of 
lumbar  analgesia. 

It  has  been  claimed  by  a  number  of  writers  that  albuminuria  is  one 
of  the  after-effects  of  spinal  analgesia.  Babcock  ^  failed  to  corroborate 
this  statement,  never  having  observed  any  clinical  evidence  of  irritation 
of  the  kidneys. 

My  own  experience  is  in  keeping  with  that  of  Babcock.  As  a  routine 
practice  the  urine  is  examined  on  the  day  following  the  injection,  and 
the  findings,  with  regard  to  albuminuria,  are  uniformly  negative. 

Various  motor  manifestations  have  been  noted.  Among  these  may  be 
mentioned  paralysis  of  one  or  both  abducens,  the  trochlearis,  and  some- 
times the  oculomotor  muscles,  coming  on  from  4  to  18  days  after  the 

^Hoseman:      Verhandl.  d.  deutsch.  Ges.  f.  Chir.,  38  Kongress  1909,  17. 
-  Babcock :      ' '  Spinal  Anesthesia,  a  Clinical  Study  of   658  Administrations, ' ' 
Fenn.  Med.  J.,  Aug.,  1909. 


584  ANESTHESIA 

analgesia,  and  disappearing  spontaneously  in  from  21  to  36  days.  Par- 
eses  of  the  legs  sometimes  remain  for  a  number  of  hours,  as  may  also 
those  of  the  rectum  and  bladder. 

Lusk  ^  correlated  the  reported  cases  of  paralytic  sequels  of  the  lum- 
bar injection  of  spinal  analgesic  agents,  finding  quite  a  number  of  in- 
stances. "These  paralyses,"  he  says,  "became  apparent  either  closely 
consecutive  to  the  recovery  of  the  patient  from  the  effects  of  the  anes- 
thetic, or  else  later  after  an  interval  of  complete  restoration  of  function 
to  the  patient.  They  are  regarded  as  due  either  to  trauma  inflicted 
on  the  nerve  structures  by  the  puncturing  needle,  or  to  some  irritative 
action  of  the  solution  injected.  It  can  be  seen  that  paralyses  attributable 
to  the  former  cause  must  be  limited  to  the  lower  half  of  the  body,  and 
that  their  onset,  as  in  the  case  of  any  severe  nerve  injury,  ought  to  be 
immediate.  The  late  occurrence  of  a  paralysis  would  seem  to  be  at  total 
variance  with  a  traumatic  origin,  and  might  consequently  be  regarded  as 
characteristic  of  an  irritation  by  the  anesthetizing  drug.  In  support  of 
the  latter  proposition  is  the  fact  that  paralysis  of  the  upper  extremity 
and  more  frequently  of  the  eye  muscles,  following  the  lumbar  injection 
of  a  spinal  anesthetic,  which  could  by  no  possible  logic  be  attributable  to 
the  traumatism  of  a  lumbar  needle  puncture,  are  characterized  by  a  late 
onset.    These  late  occurring  paralyses  are  sometimes  permanent." 

Persistent  paralyses  are  very  rare,  according  to  Fisher.^  When  they 
do  occur,  according  to  this  writer,  they  are  referable  to  imperfect  asepsis 
(spinal  meningitis),  or  to  the  injection  of  a  too  highly  concentrated,  irri- 
tative solution. 

In  my  first  paper,^  under  the  head  of  after-effects,  the  statement  is 
made  that  in  all  cases  whatever  after-effects  were  noted  were  of  a  tem- 
porary nature.  In  only  one  case  (cited  by  Lusk)  were  there  any  seri- 
ous symptoms  following  operation. 

In  the  case  referred  to  the  patient,  a  male  child  7  years  of  age,  was 
in  a  very  poor  general  condition,  with  a  marked  lumbar  kyphosis,  and 
a  large  psoas  sinus  with  small  inguinal  opening.  Operation  consisted  in 
the  enlargement  of  the  sinus,  curettage  of  the  bodies  of  the  third  and 
fourth  lumbar  vertebrae.  The  cocain  solution,  9  minims  of  a  one  per 
cent  solution,  was  injected  to  the  right,  between  the  twelfth  dorsal  and 
first  lumbar  vertebrae,  thus  avoiding  the  site  of  the  spinal  curvature.  In 
9  minutes  after  the  injection,  analgesia  was  present  over  the  entire  body, 
with  the  exception  of  a  space  bounded  behind  by  the  posterior  fontanelle, 
in  front  by  the  point  of  the  chin,  and  laterally  on  each  side  by  the  angle 
of  the  jaw,  the  malar  bone,  the  temporal  ridge,  and  the  parietal  boss. 

^Luak,   William   C. :      "The   Anatomy   of    Spinal   Puncture,   with   Some   Con- 
siderations on  Technique  and  Paralytic  Sequels,"  Ann.  of  Surg.,  Oct.,  1911. 
^Fisher:      " L 'Anesthesie   rachidienne, "    These   de  Paris,   1911. 
'Bainbridge:     0-p.  cit.,  Med.  Bee,  Dec.  15,  1900. 


SPINAL    ANALGESIA    AND     SPINAL    ANESTHESIA        585 

Some  nausea  and  vomiting  occurred  for  a  few  minutes  after  the  injec- 
tion. During  the  operation  the  patient  was  free  from  pain,  and  showed 
no  sign  of  nervousness.  He  answered  questions  and  manifested  a  full 
command  of  his  faculties.  Analgesia  disappeared  in  1%  hours.  Before 
operation,  the  temperature  was  98.4° ;  pulse,  126 ;  respiration,  34. 
One  hour  after  operation,  temperature,  100. G° ;  pulse,  108;  respiration, 
36.     The  patient  vomited  twice  during  the  night.     The  pulse  was  good. 

The  day  following  the  operation  the  child  was  restless  at  intervals, 
and  cried  out.  An  ice  cap  was  applied,  sodium  bromid  given  in  small 
doses,  and  the  bowels  thoroughly  opened.  The  second  day  after  opera- 
tion the  patient  seemed  stupid,  and  was  apparently  unable  to  express  his 
desires  in  words.  He  did  not  move  the  right  arm  and  hand,  and  the  legs 
were  drawn  up.  There  was  a  slight  elevation  of  temperature,  with  weak 
and  rapid  pulse.  The  third  day  was  marked  by  a  continuation  of  the 
stupidity,  failure  to  talk,  and  slight  movement  of  the  right  arm.  Strych- 
nin and  digitalin  in  small  doses  were  administered  hypodermatically. 
Improvement  then  began  to  be  noted,  ability  to  move  the  right  arm 
slowly  returned,  the  legs  could  be  extended,  and  the  patient  began  to 
talk.  One  month  after  operation  he  was  in  excellent  condition,  and  bet- 
ter than  before  operation. 

In  a  later  paper  ^  the  following  statement  occurs :  "Of  the  many 
scores  of  cases  upon  which  I  have  operated  in  this  way,  the  ages  have 
varied  from  4  months  to  67  years.  With  cocain  as  an  agent,  and  with 
my  present  technique,  I  have  had  no  failures  and  no  serious  after-effects. 
Many  of  the  patients  have  been  under  my  observation  for  several  years 
after  the  operation  without  any  deleterious  effects  being  noted.  The 
prophesied  evil  to  the  cord — which  the  needle  should  never  touch — has 
not  been  seen  in  any  cases  coming  under  my  observation." 

This  early  experience,  which  was  almost  exclusively  with  cocain,  has 
been  corroborated,  in  the  main,  during  the  years  which  have  elapsed  since 
the  introduction  of  the  method.  In  1,065  cases,  in  hospital  and  private 
practice,  and  with  other  agents  as  well  as  with  cocain,  I  have  had  only 
1  death  (with  the  diffusible  stovain  solution,  probably  due  to  status 
lymphaticus;  one  case  of  temporary  partial  paralysis  (see  p.  584);  one 
case  of  failure  to  induce  analgesia,  due  to  idiosyncrasy  (see  p.  623) ;  one 
case  of  failure  due  to  so-called  "dry  spine"  (see  p.  624) ;  and  two  cases, 
with  alypin,  in  which  there  was  considerable  respiratory  depression.  In 
all  the  other  cases  there  were  no  accompanying  or  postoperative  symp- 
toms of  permanent  or  serious  moment. 

^Bainbridge:      "Further  Eemarks  on  Spinal   Analgesia."     Eead   before   the 
Med.  Soc.  of  the  Co.  of  Westchester,  Yonkers,  March  15,  1904. 


586  ANESTHESIA 


INDICATIONS    AND    CONTEAINDICATIONS 

The  extremes  of  opinion  with  reference  to  the  safety  of  spinal  anal- 
gesia have  been  expressed  by  Murphy  ^  and  Jonnesco.^  The  former 
said:  "The  mortality  of  spinal  analgesia  is  such  as  to  cause  it  to  be 
abolished  as  an  analgesic  of  choice,  if  not  sufficient  to  cause  statutory 
enactments  against  its  use."  The  latter  holds  that  there  are  no  contra- 
indications for  "general  spinal  anesthesia,"  which,  according  to  his  be- 
lief, is  absolutely  safe,  has  never  caused  a  death  nor  produced  any  im- 
portant complications,  early  or  late,  is  infinitely  superior  to  inhalation 
anesthesia,  is  within  the  reach  •)f  all,  and  may  be  employed  with  any 
patient. 

Between  these  two  extremes  of  opinion  may  be  found  various  degrees 
of  conservatism  and  radicalism.  Eeference  to  the  views  of  a  few  who 
have  written  upon  the  subject  will  serve  to  show  how  widely  divergent 
they  are  concerning  the  indications  and  contraindications  for  spinal 
analgesia. 

Bier,  speaking  before  the  German  Medical  Congress  in  April,  1909, 
cautioned  against  indiscriminate  resort  to  spinal  analgesia,  and  ad- 
vised its  restriction  to  pelvic  operations  and  operations  upon  the  lower 
extremities. 

According  to  Buxton,^  the  consensus  of  opinion  narrows  the  limits 
of  the  employment  of  this  method,  excluding  from  its  use  the  following 
individuals:  "The  wounded  in  war,  children,  persons  over  65,  syphi- 
litics,  those  who  have  some  infective  or  septic  disease,  sufferers  from 
serious  heart  or  nerve  lesions,  arteriosclerosis,  the  nervous  and  the  alco- 
holic, those  who  have  albuminuria,  and  diabetics."  "This  list,"  he  con- 
tinues, "comprises  the  opinions  of  various  experts  and  narrows  the  field 
very  considerably,  but  it  is  only  fair  to  say  that  many  able  surgeons 
who  adopt  the  spinal  puncture  are  prepared  to  risk  the  dangers  of  the 
conditions  named  and  do  not  select  their  cases." 

Matas*  limited  the  indications:  (1)  To  adults,  and  to  reasonable 
persons  who  have  good  self-control,  thereby  excluding  children,  hysteri- 
cal patients,  and  the  insane;  (2)  to  patients  in  whom  the  methods  of 
local  or  regional  anesthesia  are  inapplicable;  (3)  to  patients  suffering 
from  emphysema,  advanced  asthma,  chronic  bronchitis,  and  other  res- 

^ Murphy,  John  B. :  "The  Practical  Medicine  Series,"  2,  Editorial  note,  28; 
"General  Surgery,"  1909. 

==  Jonnesco :     Op.  cit.,  Brit.  Med.  J.,  Nov.  13,  1909. 

3  Buxton,  Dudley  W. :  "  Discussion  on  Spinal  Analgesia, ' '  Section  on  Phar- 
macology and  Therapeutics,  Brit.  Med.  Assn.,  Brit.  Med.  J.,  Sept.  18,  1909,  786. 

4  Matas,  Eudolph :  ' '  Local  and  Regional  Anesthesia  with  Cocain  and  Other 
Analgesic  Drugs,  Including  the  Subarachnoid  Method,  as  Applied  in  General 
Surgical  Practice,"  Phila.  Med.  J.,  Nov.  3,  1900. 


SPINAL    ANALGESIA    AND    SPINAL    ANESTHESIA        587 

piratory  affections  in  whom  a  general  inhalation  anesthetic  is  absolutely 
contraindicated ;  in  advanced  cardiac  cases  with  degenerative  lesions 
(on  account  of  the  possible  depressing  effects  of  the  injection  and  ex- 
citement of  the  circulation) ;  (4)  in  the  majority  of  cases  in  which  the 
painful  part  of  the  operation  is  not  likely  to  be  prolonged  beyond  one 
hour  arid  a  half.  Matas  also  acknowledges  its  indication  in  labor,  espe- 
cially in  nephritic  patients. 

Babcock  ^  employed  spinal  analgesia  "in  the  most  serious  types  of  dis- 
ease requiring  operation  below  the  level  of  the  diaphragm  where  the  pa- 
tient suffered  from  severe  shock,  hemorrhage,  marked  sepsis  or  toxemia, 
or  in  conditions  of  extreme  debility." 

Gray  ^  has  found  the  method  to  be  particularly  indicated  in  many 
cases  of  abdominal  surgery,  preventing  shock  and  reducing  mortality 
25  or  30  per  cent. 

Leedham-Green,^  after  an  exhaustive  experience  with  the  method, 
found  it  to  be  indicated  in  dealing  with  gravely  debilitated  patients,  such 
as  those  suffering  from  chronic  intestinal  obstruction,  extravasation  of 
urine,  senile  gangrene,  and  the  like,  where  the  disturbance  occasioned 
by  a  general  anesthetic  often  robs  the  patient  of  his  chance  of  recov- 
ery. He  also  found  it  to  be  of  great  value  for  catheterization  of  the 
ureters  in  patients  with  highly  sensitive  bladders,  as  in  cases  of  tubercu- 
losis. 

Canny  Eyall  *  uses  the  method  for  operations  on  all  parts  of  the 
body.  Craniotomy,  excision  of  the  sympathetic  ganglia,  extirpation  of 
the  larynx,  and  excision  of  one-half  of  the  tongue,  with  removal  of  the 
glands  from  both  sides  of  the  neck,  are  some  of  the  operations  performed 
by  him  under  spinal  analgesia. 

Summing  up  the  findings  of  many  surgeons,  it  would  seem  that  the 
method  is  generally  conceded  to  be  contraindicated  in  persons  suffering 
from  concomitant  affections  of  the  heart,  lungs,  and  kidneys;  from  defi- 
nite lesions  of  the  nervous  system,  especially  of  the  spinal  cord;  from 
sepsis  or  pyemia;  from  recent  lues,  and,  according  to  some,  from  the 
later  manifestations  of  this  disease.  Persons  already  in  shock,  or  col- 
lapse, are  not  suitable  subjects  for  this  method,  and  for  this  reason  it  is 
considered  by  some  to  be  unsuitable  for  war  surgery. 

It  may  be  generally  conceded,  also,  that,  as  a  rule,  the  method  should 
be  employed  for  operations  below  the  costal  border,  being  especially  indi- 
cated for  operations  upon  the  genital  organs,  perineum  and  rectum,  and 

^Babcock:     Op.  cit.,  Penn.  Med.  J.,  Aug.,   1909. 

'  Gray :  ' '  Indications  for  the  Employment  of  Spinal  Anesthesia  in  Ab- 
dominal Surgery,"  Brit.  Med.  J.,  Sept.  2,   1911. 

' Leedham-Green :  "Discussion  on  Spinal  Analgesia,"  Section  on  Pharma- 
cology and  Therapeutics,  Brit.  Med.  Assn.,  Brit.  Med.  J.,  Sept.  18,  1909,  789. 

*  Eyall:     Brit.  Med.  J.,  June  19,  1909. 


588  ANESTHESIA 

upon  the  lower  extremities.  As  is  well  known,  many  surgeons  do  not 
subscribe  to  these  limitations. 

The  method  has  been  found  uniformly  satisfactory  in  a  considerable 
number  of  infants  and  young  children  in  whom  I  have  employed  it.  The 
youngest  child  operated  upon  by  me  under  spinal  analgesia  ^  was  a  male 
3  months  old,  in  very  poor  general  condition,  suffering  from  double 
inguinal  hernia,  with  danger  of  incarceration.  Incarceration  finally  oc- 
curred, and  the  patient  was  operated  upon  under  chloroform  anesthesia. 
Active  stimulation  was  necessary  during  the  narcosis.  The  patient  re- 
covered from  this  operation,  but  the  other  side  became  strangulated  some 
days  later.  The  patient  was  in  such  poor  general  condition,  in  addition 
to  having  developed  bronchitis  and  having  undergone  an  operation  so 
shortly  before,  that  it  was  deemed  unwise  to  resort  to  a  second  general 
anesthesia.  Spinal  cocain  analgesia  was  employed  March  19,  1901. 
Point  of  puncture,  between  third  and  fourth  lumbar  vertebras;  amount 
of  cocain,  6  minims  of  a  one  per  cent  solution.  Injection,  11 :33  a.  m. 
Analgesia  to  the  level  of  the  diaphragm  at  11 :40.  Operation  begun  at 
11 :40i/2-  Infant  began  to  cry  before  the  needle  was  inserted  in  the  back, 
and  continued  to  cry  until  the  feeding  bottle  with  a  small  quantity  of 
milk  was  allowed.  Vomited  once.  There  was  no  pain,  and  the  patient 
remained  quiet  the  greater  part  of  the  time.  The  sac  was  separated 
and  opened,  exposing  intestines,  the  appearance  of  which  confirmed  the 
necessity  for  operation.  When  the  constricted  neck  of  the  sac  was  en- 
larged a  coil  of  intestine  came  down.  Difficulty  was  experienced  in  re- 
ducing the  intestine,  and  a  few  breaths  of  chloroform  were  given  for  the 
purpose  of  still  further  relaxing  the  muscles  and  quieting  the  child,  who, 
by  this  time,  had  become  frightened  at  the  efforts  to  place  the  loop  of 
intestine  back  in  the  abdominal  cavity.  The  suturing  of  the  abdominal 
wair  and  the  completion  of  the  operation  were  accomplished  under  the 
analgesia  from  the  cocain. 

At  the  end  of  the  operation,  at  12:15,  the  loss  of  the  pain  sense  was 
complete  to  the  level  of  the  diaphragm.  There  was  no  vomiting  from 
the  time  of  the  initial  emesis  until  the  chloroform  was  administered. 
To  those  present  at  the  operation,  it  was  apparent  that  a  general  anes- 
thetic would  have  proved  fatal  to  the  child.     Perfect  recovery  resulted. 

The  most  striking  report  of  the  application  of  spinal  analgesia  in 
children  comes  from  Gray,^  who  published  an  interesting  series  of  ob- 
servations in  300  cases  in  infants  and  young  children,  the  youngest  be- 
ing 12  hours  old,  the  oldest  13  years.     Of  the  operations  performed,  190 

^Bainbridge:      Op.  cit.,  Archives  of  Pediat.,  July,  1901,  Case  XII. 

*  Gray,  H.  Tyrrell:  (1)  "A  Study  of  Spinal  Anaesthesia  in  Children  and  In- 
fants, from  a  Series  of  200  Cases,"  Lancet,  Sept.  25,  Oct.  2,  1909;  (2)  "A  Fur- 
ther Study  of  Spinal  Anaesthesia  in  Children  and  Infants,"  Lancet,  June  11, 
1910. 


SPINAL    ANALGESIA    AND    SPINAL    ANESTHESIA        589 

were  upon  the  trunk,  and  104  upon  the  extremities.  Failure  to  obtain 
anesthesia  resulted  in  10  out  of  the  300  cases. 

Of  the  first  100  cases,  9  children  died  subsequently  from  diseases  for 
which  they  were  operated  upon.  Necropsy  showed  no  abnormality  in  the 
nerve  roots,  the  cord,  or  its  membranes. 

In  the  second  series  of  100  cases  there  were  no  deaths  from  the  spinal 
analgesia. 

In  the  third  series  of  100  cases  the  author  reports  one  death  under 
analgesia.  The  patient  was  in  such  condition  that  operative  relief 
seemed  imperative,  and  death  was  practically  certain  under  general  anes- 
thesia. Necropsy  in  this  case  showed  that  both  lungs  were  completely 
collapsed;  that  there  was  pneumothorax  on  both  sides;  that  the  left  side 
of  the  diaphragm  was  extensively  infiltrated,  with  malignant  new  growth 
extending  into  the  left  pleura;  that  there  Avere  several  nodules  on  the 
under  surface  of  the  right  side  of  the  diaphragm  and  metastatic  de- 
posits in  various  other  regions;  and  that  the  growth  from  which  the  pa- 
tient was  suffering  was  a  retroperitoneal  sarcoma,  involving  kidney, 
pancreas,  etc.  The  outcome  in  such  a  case  cannot  be  considered  as  cor- 
roborative evidence  of  the  alleged  contraindication  of  infancy  and  child- 
hood. 

In  concluding  his  last  report,  Gray  says:  "Such  disadvantages  as 
are  consequent  on  the  use  of  this  method  are  very  greatly  overshadowed 
by  the  advantages  to  the  patient  and  surgeon  in  certain  cases.  I  believe 
that  spinal  analgesia  is  urgently  called  for  on  all  occasions  where  the 
after-progress  of  a  case  is  likely  to  be  influenced  by  shock  during  opera- 
tion, and  often  in  cases  when  its  employment  is  of  definite  assistance  to 
the  surgeon  in  doing  his  work  as  perfectly  as  possible." 

Waugh,^  of  the  Great  Ormond  Street  Hospital  for  Sick  Children, 
says  concerning  spinal  analgesia  in  children :  "So  striking  is  the  imme- 
diate result,  as  witnessed  by  the  surgeon,  that  for  my  own  part  all  opera- 
tions on  children  below  the  level  of  the  fifth  thoracic  nerve  involving 
considerable  shock  are  unhesitatingly  performed  under  spinal  anesthesia 
as  the  anesthesia  par  excellence  for  such  cases."  "That  I  have  been 
able,"  he  continues,  "to  resect  six  inches  of  intestine  for  acute  obstruc- 
tion in  a  baby  eighteen  hours  old,  perform  a  lateral  anastomosis  by  suture 
in  the  ordinary  way,  and  .send  the  child  out  of  the  hospital  in  a  fort- 
night's time  is  a  striking  testimony  to  its  value."  He  adds  that  he  has 
completely  abandoned  the  use  of  general  anesthesia  for  children  in  all 
cases  of  acute  appendicitis,  intussusception,  and  acute  intestinal  obstruc- 
tion, which  cases  form  no  small  share  of  the  operative  work  in  a  large 
children's  hospital. 

Preleitner,^  in  Escherich's  clinic,  had  an  experience  of  -40  cases  in 

^  Waugh,  George  E. :     Personal  commmiicatioii,  1911. 
"Preleitner:     Munch,  med.  Woch.,  1905,  52. 


590  ANESTHESIA 

children,  with  discouraging  results.  Fraenkel/  discussing  Preleitner's 
paper,  held  that  spinal  analgesia  does  not  eliminate  the  psychical  factors, 
for  which  reason  the  method  had  not  obtained  a  foothold  in  the  surgery 
of  children. 

Barker  ^  excluded  children  from  his  list  of  patients,  along  with  "ob- 
viously nervous  and  excitable  people.'^ 

Gray,^  commenting  upon  such  experiences,  stated  that  they  are  en- 
tirely contradicted  by  his  own  experience.  "From  the  psychical  aspect," 
he  says,  "no  more  suitable  patients  for  spinal  anesthesia  could  be  found, 
since  ignorance  is  their  safeguard  against  panic,  and  it  may  be  stated 
generally  that  the  younger  the  children  the  more  satisfactory  are  they 
in  this  respect."  The  most  troublesome  age,  in  his  experience,  is  between 
2  and  5  years,  children  of  this  age  being  with  greater  difficulty  kept 
quiet. 

Personal  experience  is  in  accord  with  that  of  Gray.  As  Attending 
Surgeon,  New  York  City  Children's  Hospitals  and  Schools,  ample  oppor- 
tunity has  been  afforded  me  to  test  the  utility  of  spinal  analgesia,  not 
only  in  infants  and  young  children,  but  in  the  highly  neurotic,  epileptic, 
and  idiotic. 

In  one  instance,*  the  patient,  female,  aged  4  years  and  10  months, 
of  very  nervous  temperament,  being  operated  upon  for  umbilical  entero- 
epiplocele,  gave  some  hysterical  manifestations  during  the  operation,  and 
cried  as  if  in  pain.  Careful  tests  proved,  however,  that  the  analgesia 
was  complete  with  reference  to  pain  sense.  ISTo  serious  accompanying  or 
post-operative  symptoms  occurred  in  this  case. 

In  another  case  ^  of  the  same  series,  the  patient,  male,  aged  9  years, 
was  an  epileptic,  operated  upon  for  congenital  malformation  of  the  glans 
and  prepuce,  with  hypospadias.  No  pain  or  nervousness  was  noted  in 
this  instance. 

Of  the  cases  reported  in  another  paper,*^  the  following  features 
were  noted:  epileptic;  highly  neurotic;  nervous  temperament;  feeble- 
minded, deaf  and  dumb,  hydrocephalic;  marked  idiocy,  with  epilepsy; 
highly  neurotic;  marked  idiocy,  with  epilepsy;  highly  neurotic; 
idiocy. 

Among  the  conclusions  formulated  in  the  last-named  paper  is  the  fol- 
lowing: "In  neurotic  patients  there  are  often  hysterical  symptoms  di- 
rectly following  the  completion  of  the  injection,  but,  as  a  rule,  in  a  few 

^Fraenkel:     Milnch.  med.   Woch.,   1905,  52. 
'  Barker:     Op.  cit.,  Brit.  Med.  J.,  March  23,   1907. 
^Gray:      Op.  cit.,  Lancet,  Sept.  25,  1909. 
"  Bainbridge :     Med.  Bee,  Dec.  15,  1900,  Case  II. 
'Ibid.,  Case  V. 

"Bainbridge:  Med.  News,  May  4,  1901,  Cases  I,  II,  VIII,  XIII,  XV,  XVI, 
XIX,  XXI,  XXIV. 


SPINAL    ANALGESIA    AND    SPINAL    ANESTHESIA        591 

moments  a  calm  follows  and  the  patient  lies  perfectly  still."  Subse- 
quent experience  bears  out  this  statement. 

It  has  been  claimed  that  convulsions  are  apt  to  follow  spinal  punc- 
ture in  epileptics.  In  personal  experience  with  16  epileptic  patients 
operated  upon  under  spinal  analgesia,  not  one  instance  of  convulsion  on 
the  table  has  been  witnessed.  No  increase  in  nervous  symptoms  was 
noted  in  any  case,  and  several  patients  were  distinctly  better  for  days 
after  the  injection.  Many  of  these  children  have  lived  for  years  after- 
ward, and  have  died  of  other  diseases,  nothing  being  found  abnormal 
with  the  cord  or  the  nerve  roots. 

The  contraindication  of  age  beyond  65  years  does  not  hold  in  all 
cases.  Weber  ^  reported  a  case  in  which  he  operated  upon  a  man  of  84 
years.  Jonnesco's  oldest  recorded  case  in  1909  was  75.  Barker  oper- 
ated upon  one  patient  71  years  of  age.  Many  other  instances  are  on 
record  of  operations  under  spinal  analgesia  in  patients  far  past  middle 
life. 

An  early  personal  case  ^  was  that  of  a  woman  67  years  of  age,  who 
was  suffering  from  complete  procidentia,  with  beginning  gangrenous 
changes  in  the  lower  part  of  the  uterus,  fatty  heart,  edema  of  the  lower 
extremities  and  marked  edema  of  the  local  parts,  and  suppression  of 
the  urine  for  twenty-four  hours  previous  to  operation.  Ether  was 
thought  to  be  contraindicated  because  of  the  absence  of  urine;  chloro- 
form had  been  tried,  but  the  patient  collapsed  under  it.  Cocain  spinal 
analgesia  was  resorted  to,  35  minims  of  a  two  per  cent  solution  being 
injected  between  the  second  and  third  lumbar  vertebrae.  Analgesia  was 
complete  below  the  clavicles  in  15  minutes,  and  lasted  2  hours  and  50 
minutes.  The  operation  lasted  only  30  minutes,  as,  after  scarification 
of  the  cervix  and  curetting,  it  was  found  possible  to  reduce  the  uterus 
inside  the  pelvis  and  to  retain  it  there  without  further  operative  pro- 
cedure. 

The  only  unpleasant  symptoms  in  this  case  were  nausea  a  few  min- 
utes following  puncture,  retching  once  or  twice,  and  slight  headache, 
with  3  degrees  elevation  of  temperature  the  night  after  the  operation. 
Eecovery  was  uneventful. 

Another  patient,  male,  66  years  of  age,  was  operated  upon  for  in- 
flamed, irreducible  right  inguinal  hernia,  January  24,  1911.  The  hernia 
could  not  be  held  by  truss,  and  gave  repeated  symptoms  of  impending 
strangulation.  In  addition  to  this  the  patient  was  suffering  from  ad- 
vanced arteriosclerosis,  enlarged  prostate,  cystitis,  and  a  double  car- 
diac lesion,  and  gave  evidence  of  an  old  healed  process  in  the  right  lung. 
The  operation  was  successfully  performed  under  spinal  analgesia,  with 

^ Weber:     J.  Am.  Med.  Assn.,  Feb.  9,  1900. 

'■'  Case  IV,  of  paper  read  before  the  Med.  Soc.  of  the  County  of  Westchester, 
Yonkers,  March  15,  1904. 


592  ANESTHESIA 

2  c.  c.  of  a  three  per  cent  stovain-dextrin  solution,  injected  between  the 
third  and  fourth  lumbar  vertebra.  There  was  no  nausea,  no  vomiting, 
or  other  untoward  symptom,  the  patient  read  throughout  the  operation, 
and  recovery  was  uneventful. 

A  man  70  years  old  was  operated  upon  by  me  August  4,  1911,  under 
cocain  spinal  analgesia,  with  18  minims  of  a  two  per  cent  solution,  in- 
jected between  the  third  and  fourth  lumbar  vertebrfe.  The  patient  for 
years  had  suffered  from  hypertrophy  of  the  prostate,  with  the  usual 
symptoms.  He  had  had  electrical  treatment  for  5  years,  with  temporary 
benefit.  For  a  year  he  had  been  in  a  pitiable  condition,  passing  urine 
almost  constantly,  in  dribbles,  with  retention  in  the  bladder  of  from 
24  to  36  ounces  of  urine,  and  having  to  wear  a  urinary  receptacle  night 
and  day.  The  urine  was  about  25  per  cent  by  volume  of  pus  and  detri- 
tus, with  blood  casts  and  albumin.  He  was  running  several  degrees  of 
temperature  when  first  seen,  early  in  July,  and  was  in  very  poor  general 
condition.  Arteriosclerosis  of  moderate  degree  added  to  the  complica- 
tions. 

The  patient  was  put  to  bed,  the  bladder  washed  out  for  a  time,  and 
the  alimentary  canal  cleared.  With  preliminary  medication  of  i/4  gr. 
morphin  and  1/200  gr.  nitroglycerin.  Young's  operation  for  prostatec- 
tomy was  performed  without  difficulty.  Analgesia  was  complete  to  the 
clavicles  in  3  minutes,  and  remained  so  during  the  entire  operation, 
which  lasted  an  hour.  There  was  slight  nausea  for  a  moment  at  the  be- 
ginning of  the  operation,  but  this  quickly  subsided.  There  were  no 
other  unpleasant  symptoms.  The  operation  was  at  12  :30  p.  m.  At  7 
p.  M.  the  temperature  was  102.8°;  pulse,  112;  respiration,  24.  At  10 
p.  M.  the  temperature  was  101° ;  pulse,  114;  respiration,  30.  At  2  p.  M. 
the  following  day,  temperature,  100.6°;  pulse,  110;  respiration,  28.  At 
6  A.  M.^  temperature,  99°;  pulse,  100;  respiration,  22.  At  3  p.  M.^  tem- 
perature, pulse,  and  respiration  were  normal.    Eecovery  uneventful. 

Spinal  analgesia  has  been  employed  in  the  most  elaborate  gynecologi- 
cal and  general  surgery,  the  variety  of  operation,  in  suitable  subjects,  be- 
ing no  contraindication. 

Wertheim,^  in  a  paper  read  before  the  joint  session  of  the  Chicago 
Medical  and  Gynecological  Societies,  October  10,  1906,  said:  "For  over 
a  year  we  used,  with  exceptionally  good  results,  lumbar  anesthesia.  We 
use  for  this  purpose  stovain  with  the  addition  of  adrenalin.  Even  very 
old  cachectic  women  with  badly  degenerated  hearts  bear  this  operation 
well  by  this  procedure." 

Barker,^  in  his  third  series  of  100  cases,  a  number  of  which  were  very 

^Wertheim:  "The  Radical  Abdominal  Operation  in  Carcinoma  of  the  Cervix 
Uteri,"  Surg.,  Gyn.  and  Obst.,  Jan.,  1907. 

*  Barker:  "A  Third  Eeport  on  Clinical  Experiences  with  Spinal  Analgesia," 
Brit.  Med.  J.,  Aug.  22,  1908. 


SPINAL    ANALGESIA    AND    SPINAL    ANESTHESIA        593 

grave  conditions,  cited,  as  the  worst  general  condition  to  be  contended 
against,  the  case  of  a  woman  48  years  of  age,  operated  on  in  the  country 
for  gangrene  of  nearly  5  feet  of  the  small  intestine  strangulated  by 
bands.  The  patient  was  pulseless,  and  cyanosed  in  face  and  hand,  with 
pulse  between  120  and  130.  About  6  eg.  (0.92  gr.)  of  stovain  placed 
her  in  comfort  in  5  minutes,  4  feet  and  9  inches  of  black  gangrenous 
bowel  were  excised,  and  the  healthy  gut  anastomosed  above  and  below, 
with  perfect  recovery. 

In  obstetric  practice  the  method  is  not  infrequently  indicated,  and 
has  been  successfully  employed  by  a  number  of  European  and  American 
obstetricians,  as  stated  in  the  section  on  history. 

Doleris  and  Malartic^  conclude  that  the  uterine  contractions  be- 
come painless  in  from  5  to  10  minutes  after  the  injection  of  from  1 
to  2  centigrams  of  cocain,  remaining  practically  painless,  though  per- 
ceptible, for  a  period  of  about  27  minutes  after  an  injection  of  71/2  milli- 
grams. Complete  analgesia,  according  to  these  authors,  has  a  duration 
of  from  1  hour  and  23  minutes  to  2i/4  hours,  with  a  dose  of  from 
1  to  2  centigrams.  The  uterine  contractions  become  energetic,  more 
frequent,  and  of  longer  duration  after  the  injection  than  before  it,  and 
in  the  interval  between  the  contractions  the  uterus  remains  in  a  condi- 
tion of  tension  during  a  variable  period. 

They  found  the  bleeding  to  be  much  less  than  usual,  and  in  a  case 
of  placenta  prgevia  the  hemorrhage  spontaneously  ceased  before  the  rup- 
ture of  the  membranes.  The  action  of  the  cocain  on  the  fetus,  in  their 
experience,  was  nil. 

Cesarian  section  has  been  successfully  performed  under  spinal  anal- 
gesia by  Sinclair,-  Hopkins,^  and  Doleris.* 

Marx  ^  recommended  spinal  analgesia  in  all  cases  in  which  the  first 
stage  of  labor  is  prolonged.  By  the  use  of  small  doses,  used  as  required, 
he  has  been  able  to  carry  a  patient  painlessly  through  labor  of  8  hours' 
duration. 

The  only  case  ^  in  which  I  have  employed  spinal  analgesia  in  ob- 
stetrics was  for  the  delivery  of  a  full-term  child  by  means  of  high  for- 
ceps operation.     The  patient,  Mrs.  H.,  26  years  of  age,  lived  in  a  tene- 

1  Doleris  and  Malartie:  "Analgesie  obstetrieale  par  injection  sous-araeli- 
noi'dienne  de  cocaine, ' '  La  Semaine  vied.,  1900,  243. 

2  Sinclair:  "Caesarian  Section  under  Cocaine  Ansestliesia, "  J.  of  Obst.  and 
Gyn.  of  Brit.  Emp.,  Sept.,  1902,  221. 

3  Hopkins:  "Case  of  Cassarian  Section  under  Spinal  Anesthesia,"  J.  Am. 
Med.  Assn.,  May  24,  1902,  1355. 

4  Doleris  and  Malartie:  Oi).  cii.,  Conipt.  rend.  d.  I.  Sac.  d'Obst.,  Cyn.  et  Fed. 
d.  Paris,  1900,  328. 

5  Marx:     Med.  Bee,  Oct.   6,   1900,   521. 

6  Bainbridge :  Eeported  before  the  Surgical  Section,  Am.  Med.  Assn.,  Atlantic 
City,  June  4-7,  1912. 


594  ANESTHESIA 

ment  house,  and  this  was  her  fifth  confinement.  Labor  began  at  6  :30 
on  the  evening  of  February  23,  1901,  the  weak  and  ineffectual  pains 
continuing  until  2  :30  a.  m.  of  February  34.  The  membrane  then  rup- 
tured, and  the  infant's  heart  beat  became  very  weak,  then  practically 
inaudible.  It"  was  determined  to  deliver  the  child  by  forceps,  under 
spinal  analgesia.  The  injection  was  made  at  3  :35  a.  m.^  20  minims  of  a 
two  per  cent  solution  of  cocain  being  introduced  between  the  third  and 
fourth  lumbar  vertebrae.  At  3  :48  analgesia  was  complete  to  the  level 
of  the  chin,  and  at  4 :20  the  child  was  born.  By  6  :55  analgesia  had 
fully  disappeared.  The  analgesia  was  so  perfect  that  the  mother  went 
to  sleep  during  the  delivery,  being  unconscious  of  the  birth  of  the  child 
until  she  was  awakened  by  its  cry. 

Ehrenfest  ^  calls  attention  to  the  following  objections  which  may  be 
urged  against  spinal  analgesia  for  general  obstetrical  use:  (1)  It  is  not 
a  harmless  procedure.  (2)  Disagreeable  symptoms  inevitably  follow  the 
injection.  (3)  It  may  have  a  toxic  effect  on  the  child,  such  cases  having 
been  reported.  (4)  The  analgesic  effect  may  disappear  just  at  the  mo- 
ment when  it  is  necessary  and  only  the  unpleasant  sequelae,  such  as 
vomiting  and  extreme  nervousness,  remain.  (5)  The  loss  of  the  active 
help  of  the  abdominal  muscles  is  a  very  decided  disadvantage. 

From  the  weight  of  conflicting  testimony  with  reference  to  the  indi- 
cations and  contraindications  for  spinal  analgesia,  it  may  be  deduced,  in 
a  general  way,  that,  granting  the  need  of  operation,  and  the  impractica- 
bility of  local  or  regional  analgesia,  the  indications  for  spinal  analgesia 
are  the  contraindications  for  general  inhalation  anesthesia.  So  far  as 
the  character  of  the  operative  procedure  is  concerned,  there  are  practi- 
cally no  contraindications  to  the  employment  of  spinal  analgesia.  With 
the  modifications  of  injection  fluid  now  in  use,  it  may  be  said  that  no 
part  of  the  body  is  under  the  ban  of  contraindication.  Despite  the  im- 
provements of  technique  and  the  extension  of  domain,  the  method  is 
employed  more  often  as  one  of  expediency  than  as  one  of  choice. 


ADVANTAGES  AND  DISADVANTAGES 

Advantages. — The  advantages  of  spinal  analgesia  may  be  stated  cate- 
gorically and  briefly  as  follows : 

(1)  Very  little  apparatus  is  required. 

(2)  The  operative  technique  presents  few  difficulties,   hence  tlie 
method  is  easy  of  application. 

(3)  The  injection  may  be  made  by  the  surgeon  himself,  thus  obvi- 

1  Ehrenfest :      "A  Few  Eemarks  on  the   Use   of   Medullaiy  Narcosis   in  Ob- 
stetrical Cases,"  Med.  Bee,  Dec.  22,  1900,  967. 


SPINAL    ANALGESIA    AND     SPINAL    ANESTHESIA        595 

ating  the  necessity  of  an  assistant.     For  emergency,  military,  and  naval 
surgery  this  is  a  distinct  advantage. 

(4)  Analgesia  is  quickly  inducted,  from  4  to  10  minutes  being  suffi- 
cient, as  a  rule,  for  the  induction  of  analgesia  as  far  as  the  diaphragm. 

(5)  The  relative  safety,  as  regards  life,  with  good  technique,  skil- 
fully executed,  is  high. 

(6)  Does  not  depress  the  heart,  like  chloroform,  or  cause  pulmo- 
nary and  renal  complications,  like  ether,  as  these  anesthetics  are  ordi- 
narily administered. 

(7)  Insures  physical  quietude  during  operation,  which  is  of  dis- 
tinct advantage  to  the  surgeon. 

(8)  Insures  the  patient's  aid,  which  may  he  desirable,  as  in  cough- 
ing mucus  or  blood  from  the  throat. 

(9)  May  save  the  life  of  patients  who,  because  of  contraindications 
to  inhalation  anesthesia,  would  be  consigned  to  their  fate  without  opera- 
tive relief. 

(10)  Controls  surgical  shock  by  blocking  off  reflexes. 

(11)  Obviates  persistent  postoperative  retching  and  vomiting, 
which  is  of  esi)ecial  advantage  in  abdominal  work. 

(12)  Lessens  postoperative  pain. 

(13)  Lessens  postoperative  restlessness  which  results  from  post- 
operative pain. 

(14)  Diminishes  the  danger  of  postoperative  pulmonary  compli- 
cations. 

(15)  Gives  "abdominal  stillness,"  emphasized  by  Jonnesco,  Gray, 
and  others,  in  connection  with  laparotomies. 

(16)  Decreases  mortality. 

Busse,^  upon  the  basis  of  experience  with  1,232  cases  of  lumbar  anal- 
gesia, points  out  the  following  advantages  of  this  method  as  compared 
with  inhalation  anesthesia: 

(1)  The  blood  pressure  is  not  seriously  affected. 

(2)  Asphyxia  is  considerably  less  frequent. 

(3)  Vomiting  during  the  operation  is  less  "common  and  less  pro- 
fuse. 

(4)  Vomiting  after  operation  occurs  less  frequently. 

(5)  Vesical  disturbances  are  reduced  to  about  one-third  to  one- 
half. 

(6)  Deaths  from  pulmonary  embolism  seem  to  become  less  com- 
mon. 

Babcock  ^  emphasizes  the  following  advantages  of  this  method  over 
general  anesthesia: 

^Busse:  PraM.  Ergehnisse  der  Gehurts.  u.  Gyn.,  1909,  1;  also,  CentralM.  f. 
Gyn.,  1910,  No.  42,  1363. 

-  Babcock ;     Pen7i.  Med.  J.,  Aug.,  1909. 


596  ANESTHESIA 

(1)  It  reduces  the  mortality  and  morbidity  of  operations. 

(2)  It  insures  physical  quietude  before,  during,  and  after  the  opera- 
tion. 

(3)  It  secures  complete  muscular  relaxation  and  a  desirable  peri- 
staltic stimulation. 

(4)  It  increases  the  patient's  comfort  and  resistance. 
Disadvantages. — The   disadvantages   of  spinal   analgesia  have  been 

variously  estimated,  from  none  at  all  to  an  overwhelming  number,  by 
the  enthusiastic  advocates  of  the  method  on  the  one  hand,  and  its  un- 
qualified opponents  on  the  other.  By  conservative  opinion  they  may  be 
summed  up  categorically  and  briefly  as  follows: 

(1)  Unpleasant  accompanying  and  postoperative  phenomena, 
which,  despite  all  precautions,  may  occur. 

(2)  Possible  dangers  from  the  analgesic  agent  ^jer  se,  which,  though 
not  so  frequent  as  formerly,  do  nevertheless  occur,  and  have  always  to 
be  borne  in  mind. 

(3)  Uncertainty  as  to  the  length  of  the  analgesia,  which  may  wear 
off  before  the  operation  is  completed. 

(4)  Uncertainty  as  to  the  exact  amount  necessary  to  produce  the 
desired  effect  in  a  given  case. 

(5)  Absolute  commitment  of  the  surgeon  to  the  consequences  of  the 
dose  injected,  the  effects  of  which,  if  untoward,  cannot  be  controlled,  as 
in  the  case  of  a  general  anesthetic,  the  dose  of  which  may  be  regulated 
to  suit  the  exigencies  of  the  individual  case. 

(6)  Consciousness  on  the  part  of  the  patient,  and  the  consequent 
possibility  of  psychic  pain,  nausea,  and  other  disturbances,  especially  on 
the  part  of  nervous  individuals. 

(7)  Incomplete  muscular  relaxation,  which  may  occur  when  relaxa- 
tion is  desirable. 

(8)  Failure  to  obtain  sufficient  cerebrospinal  fluid  to  warrant  mak- 
ing the  injection,  sometimes  attributed  to  so-called  "dry  spine,"  and 
occurring  at  times  in  the  experience  of  skillful  operators. 

(9)  Possible  injury  to  and  irritation  of  the  spinal  cord  and  nerve 
roots. 

DEATHS 

It  has  been  repeatedly  stated  that  death  statistics  are  of  no  practical 
value  in  determining  the  direct  toxic  working  of  the  drugs  employed 
for  the  induction  of  spinal  analgesia,  the  question  being  mainly  one  of 
dosage.  Deaths  have  been  reported  in  connection  with  each  of  the 
drugs  in  common  use,  whether  justly  attributable  directly  to  the  action 
of  the  drug  in  any  case  being  a  debatable  point.  It  is  fair  to  assume 
that  other  factors  are  to  be  considered  in  connection  with  fatalities  re- 


SPINAL    ANALGESIA    AND     SPINAL    ANESTHESIA        597 

suiting  from  spinal  analgesia.  For  all  surgeons,  except,  possibly,  the 
few  peculiarly  expert  operators  who  recognize  no  limitations  to  the 
method,  the  selection  of  the  subject  for  spinal  analgesia  must  exert  con- 
siderahle  influence  over  the  mortality  record.  The  entire  management 
of  the  case,  including  the  surgical  interference,  bears  a  direct  relation- 
ship to  the  safety  of  the  method.  Despite  every  possible  safeguard,  how- 
ever, deaths  have  occurred,  and  will  doubtless  continue  to  occur,  with 
this  as  with  every  other  method. 

Chiene  ^  collected  the  reports  of  over  12,000  cases,  with  22  deaths, 
or,  roughly,  1  death  in  570.  He  holds  that,  if  the  cases  be  analyzed  in 
which  death  occurred,  it  will  be  found  that  very  few  can  be  attributed 
solely,  or  even  partially,  to  the  anesthetic.  In  analyzing  the  table  of 
statistics  given  by  Strauss,^  in  which  the  latter  collated  22,717  cases, 
with  46  deaths,  Chiene  found  that  25  of  the  45  deaths  reported  oc- 
curred when  cocain  was  iTsed,  which  works  out  at  21  deaths  in  15,842 
cases  where  other  drugs  were  employed,  or  1  in  754.  Only  3  of  these 
were  stated  to  be  clearly  due  to  the  analgesic  agent,  or  1  in  5,282, 
and  9  more  seemingly  in  connection  with  the  agent;  in  all,  1  in 
1,320. 

Compared  with  results  obtained  in  a  similar  number  of  cases  by  gen- 
eral anesthesia,  Chiene  considered  the  above  figures  not  so  unfavorable 
as  some  writers  have  claimed. 

Jonnesco  ^  gives  the  following  statistics :  From  July  5,  1908,  to  Nov. 
8,  1909,  758  cases  were  operated  upon  by  Jonnesco  or  his  assistants. 
Two  cases  in  London  and  23  in  America  bring  the  total  to  783,  of  which 
195  were  superior  dorsal  and  588  dorsolumbar  injections.  If  to  this 
number  be  added  603  earlier  lumbar  analgesias,  he  has  a  record  of  1,386 
rachianesthesias,  without  mortality. 

In  a  later  communication  Jonnesco  *  gives  the  following  personal  sta- 
tistics :  One  thousand  and  five  cases,  from  Jiily  8,  1908,  to  September  29, 
1910,  including  238  high  analgesias  (operations  on  the  head,  neck,  su- 
perior extremities,  and  thorax),  and  267  low  analgesias  (operations  on 
the  abdomen,  pelvis,  perineum,  and  inferior  extremities).  These  statis- 
tics include  2  cases  operated  upon  by  Jonnesco  in  London  and  23  in 
America.  The  ages  of  the  patients  varied  from  1  month  to  82  years. 
He  had  no  deaths,  he  avers,  due  to  the  method,  in  the  2  years.  Two  fatal 
cases  among  high  analgesias  occurred  among  his  Eoumanian  colleagues, 
but  these  were  referable  to  overdoses  of  stovain  or  strychnin. 

» Chiene :     Op.  cit.,  Brit.  Med.  J.,  Sept.  18,  1909,  785. 

^Strauss:  "Der  Gegenwartige  Stand  tier  Spinalanalgesie, "  Deutsch.  Zeit.  f. 
CTiir.,  July,  1907,  275. 

=' Jonnesco:     Atn.  J.  of  Surg.,  op    cit.,  1910,  29,  33. 

^Jonnesco:  "La  rachi-anesthesie  generale, "  B,ev.  de  Therapeut.  med.-chir., 
Dec.  1,  1910,  798. 


598  ANESTHESIA 

Kohler  ^  collected  7,780  cases,  with  12  deaths.  Chaput  ^  knew  of 
no  deaths  among  7,000  cases.  Tuffier  ^  reported  one  death  (not  posi- 
tively attributable  to  the  analgesia)  in  11  years.  Gray  *  reported  one 
death  in  his  series  of  300  cases  in  children.  Barker  ^  formulated  a  table 
of  the  results  at  5  British  hospitals  working  on  exactly  the  same  princi- 
ples and  technique,  and  with  the  same  instruments  and  solutions  care- 
fully prepared.  This  table  represents  3,354  cases,  including  775  cases 
under  his  own  observation,  in  which  there  were  only  3  deaths,  or  0.1  per 
cent. 

Michelsson,*'  discussing  the  various  attempts  to  calculate  the  mortality 
of  spinal  analgesia  on  the  basis  of  statistical  compilations,  gives  the  fol- 
lowing divergent  results :  Tomachewski  calculates  the  mortality  of  spinal 
analgesia  as  1:17847;  Strauss,  1:2524;  Chiene,  1:570;  Hohmeier, 
1 :  200.  The  figures  of  Strauss  are  held  by  Michelsson  to  be  nearest  the 
truth  of  the  matter,  although  the  mortality  percentage  is  stated  a  little 
too  high,  omitting  cocain  analgesia,  the  mortality  amounting  to  about 
1:3500. 

In  a  personal  experience  of  1,065  cases,  covering  an  extensive  variety 
of  operations  upon  patients  ranging  in  age  from  3  months  to  70  years, 
there  has  been  one  fatality.^  This  might  easily  be  attributed  to  other 
causes  (see  pp.  585,  625). 

It  is  worthy  of  note,  in  connection  with  the  subject  of  mortality  due 
to  the  subarachnoid  injection  of  anesthetic  agents,  that  Engsted^  has 
reported  the  successful  use  of  ether  as  an  antidote  to  cocain  and  other 
drugs  employed  as  local  or  spinal  analgesics.  He  has  been  able,  by  this 
means,  to  revive  patients  who  were  practically  in  extremis.  The  best 
results  are  obtained,  he  holds,  when  ether  is  administered  to  the  degree 
of  mild  surgical  narcosis,  or  even  less.  A  mask  is  employed,  and  the 
vapor  given  by  the  drop  method,  thus  preventing  adding  to  the  danger 
by  excluding  air  from  the  lungs  already  engorged  with  venous  blood. 

^Kohler:     Deutsch.  Zeit.  f.  Cliir.,  1909,  16. 

-Chaput:     Brit.  Med.  J.,  May  30,  1908,  1330. 

*  Tuffier:     Personal  communication,  March,  1911. 

••Gray:    O'p.  cit.,  Lancet,  June  11,  1910. 

=  Barker:     Brit.  Med.  J.,  March  16,  1912,  597. 

*Michelson:      Op.  cit.,  Ergebnisse  d.  Chir.  und  Ortlio.,  4,  1912. 

■^  Bainbridge :  "Spinal  Analgesia — Development  and  Present  Status  of  the 
Method,  with  Brief  Summary  of  Personal  Experience  in  1,065  Cases,"  J.  Am. 
Med.  Assn.  Read  before  the  Section  on  Pharmacology  and  Therapeutics,  in  joint 
session  with  the  Section  on  Pathology  and  Physiology,  American  Medical  Associa- 
tion, Atlantic  City,  June  6,  1912. 

^Engsted,  J.  E. :  "Ether:  An  Antidote  of  Cocain  and  Stovain  Poisoning," 
J.  Am.  Med.  Assn.,  March  19,  1910,  964. 


SPINAL    ANALGESIA    AND    SPINAL    ANESTHESIA        599 


ANALGESIC    AGENTS 

The  Therapeutic  Committee  of  the  British  Medical  Association  ^  in- 
vestigated the  following  local  analgeyic  agents:  stovain,  novocain,  tropa- 
cocain,  beta-eucain,  alypin,  beta-eucain  lactate,  nirvanin,  holocain  hy- 
drochlorid,  acoin,  orthoform  (new),  and  anesthesine.  (See  Chapter 
XX.) 

Among  the  points  to  which  especial  attention  was  directed  in  this 
investigation  was  the  suitability  of  the  agent  for  medullary  narcosis. 
Preliminary  experiments  reduced  the  list  to  4,  viz. :  stovain,  novocain, 
tropacocain,  and  beta-eucain  lactate,  which  were  subjected  to  further 
investigation.  After  comparing  these  drugs  one  with  the  other,  the 
conclusion  was  reached  that  novocain  is  the  most  satisfactory  for  gen- 
eral use.  "Its  anesthetic  action  is  equal  to  that  of  cocain,  and  its  tox- 
icity and  general  destructive  power  on  the  tissues  are  very  much  less." 

Of  the  four  drugs  mentioned  in  the  above  report,  stovain,  novocain, 
and  tropacocain  are  most  generally  used,  though  some  operators,  myself 
among  the  number,  still  find,  at  times,  a  place  for  cocain.  Various  modi- 
fications of  tlie  analgesic  solution  and  its  preparation  have  been  adopted. 
A  few  are  mentioned  here,  but  more  are  given  in  Chapter  XX. 

Cocain,  tropacocain,  stovain,  and  novocain  are  considered  in  the  or- 
der of  their  introduction  for  purposes  of  spinal  analgesia,  and  not  with 
reference  to  their  relative  merits.  Personal  experience  with  other  agents, 
eucain  and  alypin,  for  example,  does  not  warrant  devoting  to  them  fur- 
ther consideration.  Eucain  was  discarded  because  it  gives  a  "patchy" 
analgesia,  and  alypin  because  it  depresses  respiration. 

The  analgesic  agents  most  commonly  employed  are  variously  modi- 
fied, the  purpose  being  to  produce  a  fluid  of  the  same,  heavier  or  lighter 
specific  gravity,  as  compared  with  the  cerebrospinal  fluid.  The  injec- 
tion fluid,  thus  modified,  is  more  or  less  difl!usible,  according  to  its  rela- 
tive specific  weight,  and,  as  a  consequence  of  the  relative  diffusibility, 
the  analgesia  produced  is  more  or  less  controllable  as  regards  its  extent. 

The  various  analgesic  solutions  may  be  classed,  according  to  their 
relative  specific  gravity,  as  follows :  ( 1 )  Analgesic  agent,  plus  water, 
plus  alcohol;  (2)  analgesic  agent,  plus  water;  (3)  analgesic  agent,  plus 
water,  plus  cerebrospinal  fluid;  (4)  analgesic  agent,  plus  cerebrospinal 
fluid  alone;  (5)  analgesic  agent,  plus  water,  plus  normal  salt  solution; 
(6)  analgesic  agent,  plus  water,  plus  dextrin,  glucose,  or  gum  arable. 

To  any  of  the  above  may  be  added,  if  desired,  adrenalin  or  some  sim- 
ilar product,  as  employed  by  Bier,  Gray,  and  many  others,  or  strychnin, 
as  suggested  by  Jonnesco. 

^  Le   Brocq :      ' '  Keport    on   the   Local    Anaesthetics   Recommended    as    Substi- 
tutes for  Cocaine,"  Brit.  Med.  J.,  March  27,  1909. 


600  ANESTHESIA 

Solutions  of  lighter  specific  gravity  than  the  cerebrospinal  fluid  are 
generally  called  diffusible,  whereas  those  of  heavier  specific  gravity  are 
called  non-diffusible  solutions.  To  the  former  class  belongs  No.  1 ;  to 
the  latter,  No.  6. 

Cocain.^ — During  the  early  days  of  spinal  analgesia  cocain  was  the 
agent  most  commonly  employed,  but  because  of  the  various  fatalities  and 
the  many  unpleasant  accompanying  and  postoperative  phenomena  which 
marked  the  experimental  stage  it  has  been  pretty  generally  abandoned. 

Allen  2  says :  "Since  1899,  when  Bier's  first  work  appeared,  cocain 
has  gradually  given  way  to  the  less  toxic  and  equally  effective  stovain, 
novocain,  or  tropacocain,  and  it  is  now  never  used."  He  considers  that 
it  has  no  place  in  spinal  analgesia.  With  this  view  probably  the  ma- 
jority of  surgeons  are  in  accord. 

A  more  favorable  opinion  of  cocain  is  expressed  by  Filliatre,^  who 
declares  that  this  agent,  employed  by  his  method,  is  absolutely  devoid 
of  danger.  His  method,  which  he  has  employed  in  1,500  cases,  consists 
in  first  withdrawing  30  c.  c.  of  cerebrospinal  fluid,  then  injecting  from 
0.5  to  2  c.  c.  of  a  2  per  cent  solution  of  cocain.  This  gives  a  dosage  of 
from  1  to  4  eg.  (0.15  -j-  to  0.6  -[-  gr.)  of  cocain. 

J.  Garland  Sherrill,  of  Louisville,  Kentucky,  has  always  found  a 
two  per  cent  solution  of  cocain  quite  satisfactory,  never  using  over  15 
minims  as  a  dose. 

Charles  Chassaignac  (private  communication),  of  New  Orleans,  has 
used  cocain  in  doses  ranging  from  1/5  to  14  S^- 

E.  Denegre  Martin  (idem),  New  Orleans,  gives  cocain  the  prefer- 
ence, employed  in  doses  of  5  minims  of  a  4  per  cent  solution. 

Simon  Marx  (idem),  New  York  City,  mentions  cocain  as  his  second 
choice,  stovain  being  first.    He  uses  cocain  in  doses  of  14  gr. 

In  a  rather  extensive  experience  with  cocain  the  results  of  Bain- 
bridge  with  this  agent  have  been  uniformly  successful  when  the  solution 
has  been  prepared  according  to  his  method.  The  dose  employed  ranges 
from  5  to  20  minims  of  a  two  per  cent,  and  from  5  to  30  minims  of  a 
one  per  cent,  solution. 

Cocain  has  been  largely  employed  as  a  standard  by  which  to  gauge 
the  toxicity  of  other  analgesic  agents.  It  is  considered  twice  as  toxic  as 
tropacocain,  about  7  times  more  toxic  than  novocain,  and  6  times  more 
toxic  than  stovain. 

While  cocain  is  more  toxic  than  other  agents,  needing,  in  conse- 
quence, more  safeguarding,  the  resulting  analgesia  is  more  profound, 
and  lasts  longer,  Avith  correspondingly  moderate  dosage. 

The  toxicity  of  cocain  has  been  attributed  by  many  writers  to  harm- 

1  For  further  data,  see  Chapter  XX. 

^Boston  Med.  and  Surg.  J.,  163,  No.  19. 

^  Ann.  d.  mal.  d.  org.  genito-urin.,  1909,  No.  13. 


SPINAL    ANALGESIA    AND     SPINAL    ANESTHESIA        601 

ful  b_y-proclucts  resulting  from  its  decomposition  l)y  the  heat  iLsed  in 
sterilizing  this  agent.  Others  contend  that  coca  in  is  not  decomposed 
by  heat,  and  that  the  unpleasant  phenomena  which  accompany  its  use  in 
some  cases  result  not  from  the  cocain  or  its  decomposition  products,  but 
from  the  water  used  in  making  the  solution. 

Tropacocain.^ — It  is  claimed  by  some  that  analgesia  occurs  sooner 
with  tropacocain  than  with  cocain,  and  that  it  is  of  longer  duration. 
Personal  experience  is  that  there  is  very  little  difference  in  these  regards. 

The  solution  recommended  by  Willy  Meyer  ^  is  as  follows : 

Tropacocain  hydrochlorate 0. 15  gm.  (23^^  grs.) 

Sodium  chlorid 0.06  gm.  (1  gr.) 

Distilled  water 10.00  gm.  (23^  drs.) 

Fifty  minims  of  this  solution  contain  5  centigrams  (5/6  gr.)  of 
tropacocain,  which  is  the  dose  usually  required.  This  dose  gives  an  anal- 
gesia sufficient  for  an  operation  lasting  1  hour  or  longer. 

The  Bier  solution  of  tropacocain,  so  largely  used,  is  put  up  in  am- 
pules containing  1.3  c.  c.  of  a  5  per  cent  solution  of  tropacocain,  with 
adrenalin  hydrochlorid,  0.00013  per  c.  c.  The  dose  of  tropacocain  usu- 
ally given  is  5  cgm.   (5/6  gr.). 

Slajiner  ^  employed  spinal  analgesia  in  2,700  cases,  during  the  years 
1901-1909,  in  his  capacity  as  chief  physician  to  the  Surgical  Depart- 
ment of  the  Laibach  General  Hospital.  In  all  these  cases  tropacocain 
was  used    (Merck's  sterilized   flasks),   the  usual   dose  being   0.07   gm. 

(1  +  gr.)- 

Colombani,'*  on  the  basis  of  1,100  operations  performed  imder  tropa- 
cocain analgesia,  advocates  as  the  usual  dose  0.08  gm.  (li^  +  gr-)- 

Erhardt  ^  recommends  the  addition  of  gum  arable  to  the  tropacocain 
solution  used  for  spinal  analgesia,  in  a  dosage  of  three  per  cent  gum  to 
a  one  per  cent  tropacocain  solution.  The  advantages  of  the  addition  are 
unmistakable,  consisting  in  the  diminution  of  the  general  toxic  manifes- 
tations, and  the  prolongation  of  the  anesthetic  effect.  The  essential 
cause  for  the  lessened  toxic  action  is  referable  to  the  delayed  absorption 
and  the  less  immediate  contact  with  the  central  nervous  structures. 

Hertel,"  after  having  performed  lumbar  analgesia  with  watery  solu- 
tions of  tropacocain,  recommends  the  addition  of  gum  arable,  which  he 
has  already  employed  in  82  cases.    Apparently  the  danger  is  diminished, 

1  See  Chap.  XX,  for  a  fuller  discussion  of  tropacocain. 
=^  Meyer,  Willy:     Med.  News,  April  13,  1901. 
sSla.iiner:     Beit.  s.  Min.  CUr.,  1910,  67. 
4Colombani:      Wiener  Min.   Woch.,    1909,   No.   39. 
5  Erhardt:      Miinch.   med.  Woch.,  1908,   No.   19,   1005.. 
eHertel:      Miinch.   med.    Woch.,   1910,   No.    16,   844. 


602  ANESTHESIA 

although  not  entirely  excluded ;  the  analgesia  seems  to  reach  higher,  and 
the  number  of  failures  is  also  apparently  diminished. 

Stovain.^ — The  Bier  compound  of  stovain  is  as  follows: 

Stovain. .- 4      per  cent 

Sodium  chlorid 0.11  per  cent 

Epirenin   borate 0.01  per  cent 

Tufiier  recommends  a  10  per  cent  solution  of  stovain  in  normal  salt 
solution. 

Chaput  uses  the  following : 

Stovain 10  per  cent 

Sodium  chlorid • . .    10  per  cent 

Distilled  water 80  per  cent 

The  Stovain-Billon  solution  so  largely  employed  is  marketed  in  am- 
pules of  2  c.  c,  each  cubic  centimeter  containing : 

Stovain 0.04  gm.  (6/10  gr.) 

Adrenalin  borate 0.00013  gm. 

Sodium  chlorid 0.0011  gm. 

Each  ampule  contains  8  cgm.  of  stovain  (1  1/5  gr.),  so  that  a  mini- 
mum or  a  maximum  dose  may  be  given. 
Barker's  compound  (stovain-glucose)  is: 

Stovain 10  per  cent 

Glucose 5  per  cent 

Distilled  water 85  per  cent 

The  glucose  was  added  by  Barker  for  the  purpose  of  obtaining  a  fluid 
of  heavier  specific  gravity  than  the  cerebrospinal  fluid.  By  this  means 
he  believed  it  would  be  possible  to  localize  the  analgesia. 

Houghton  "  has  contributed  a  report  of  400  cases  operated  upon  un- 
der spinal  analgesia  induced  with  the  Barker  stovain-glucose  solution. 
From  his  previous  experience-^  with  other  drugs,  followed  by  the  series 
of  cases  in  which  he  confined  himself  to  the  use  of  the  Barker  solution,  he 
concludes  that  the  5  per  cent  solution  of  stovain  and  glucose  has  given 
the  most  consistent  and  reliable  results.  In  this  series  there  was  no 
case  of  failure  to  enter  and  to  inject  the  spinal  sac,  no  case  in  which  the 
injection  failed  to  induce  adequate  analgesia,  and  no  case  Avhich  gave 
cause  for  any  anxiety  as  to  the  safety  of  the  method.  In  life-saving 
operations,  such  as  amputation   of  the   leg  for  diabetic   gangrene,   or 

1  For  further  information  on  Stovain,   see  Chapter  XX. 

2  Houghton,   J.   W.   H. :      "  Spinal  Analgesia.     Eeport   of   400   Operations   at 
the  Military  Hospital,  Aldershot, "  Lancet,  Oct.  12,  1912,  1008. 

3  Boyal  Army   Med.  Corfs.  J.,  Aug.,   1908,   and  Oct.,   1909. 


SPINAL    ANALGESIA    AND     SPINAL    ANESTHESIA        603 

operaticn  upon  a  patient  with  advanced  cardiac  disease,  in  wliieh  neither 
chloroform  nor  ether  is  admissible,  stovain  can  be  used.  In  Houghton's 
experience  there  was  absence  of  shock  during  operation,  and  tlie  muscular 
relaxation  was  so  complete  that  much  less  time  was  required  for  the  com- 
pletion of  the  operation  than  with  chloroform. 

The  dextrin-stovain  solution  employed  by  Gray  consists  of  stovain, 
3  per  cent,  with  de:;trin  and  suprarenin  in  saline  solution.  This  solu- 
tion is  placed  upon  the  market  in  ampules  of  2  c.  c.  each,  one  ampule 
being  sufficient  for  the  induction  of  analgesia  to  the  diaphragm,  and 
often  above. 

The  dose  is  0.015  to  0.04  gm.  (1/5  to  i/o  gr.)  of  stovain. 

The  stovain-strychnin  solution  suggested  and  so  extensively  used  by 
Jonnesco  in  the  so-called  high  analgesia  must  be  prepared  in  advance 
of  the  time  of  operation,  inasmuch  as  the  strychnin  sulphate  takes  some 
time  to  dissolve. 

The  amount  of  strychnin  and  stovain  in  the  solution  varies  with  the 
site  of  injection,  the  patient's  age,  and  general  condition.  Jonnesco  uses 
from  1  to  10  cgm.  of  stovain. 

Babcock,  who  advocates  a  solution  of  lighter  specific  gravity  than 
the  cerebrospinal  fluid,  uses  the  following  combination,  made  by  Mor- 
gan, of  Philadelphia : 

Stovain 08  p.  c. 

Ac.  Lactic 02 

Abs.  Alcohol 20 

Aq.  dest q.  s.   2.00 

The  alcohol  content  of  this  solution  is  reduced  in  strength  about  one- 
half  by  the  admixture  of  the  solution  with  the  cerebrospinal  fluid  before 
it  is  thrown  into  the  spinal  canal. 

Lambotte,  of  Antwerp,  and  his  assistants  have  employed  stovain  in 
over  1,800  cases,  with  uniformly  satisfactory  results. 

It  may  be  of  interest  to  note  that  at  Sing  Sing,  the  New  York  State 
prison  at  Ossining,  stovain  has  been  used  exclusively  since  August,  1908, 
for  operations  below  the  level  of  the  umbilicus.^  The  results  have  been 
uniformly  successful,  with  no  deaths  due  to  the  anesthetic,  in  approxi- 
mately 400  operations  performed  by  H.  E.  Mereness,  Jr.,  and  F.  E.  Let- 
tice.    The  Billon  preparation  is  employed. 

Novocain.- — The  novocain-suprarenalin  solution  advocated  by 
Braun,"  who  first  suggested  the  addition  of  adrenalin  to  analgesic 
agents,  is  put  up  in  ampules  of  3  c.  c.  each,  containing: 

^Personal  communication   from   Mereness,   Feb.    23,   1913. 
^  For   f urtlier  information  on   Novocain,   see   Chapter   XX. 
'Braun:     Deutseh.  Monatsli.  Jah^iheill-.,  June,  1906. 


604  ANESTHESIA 

Novocain 0.15  gm    (1  to  1|  gr.) 

Suprarenalin 0.000325  gm.     (1-250  gr.) 

This  is.  equal  to  five  minims  of  suprarenalin  solution,  1-1000,  to  3 
c.  c.  of  sterilized  distilled  water.  Of  this  solution  2  to  3  c.  c.  may  be 
used. 

Meissner  ^  reports  600  lumbar  analgesias  from  the  Tubingen  Surgical 
Clinic,  in  all  but  40  of  which  novocain  was  employed,  first  in  5  per  cent 
solution  (2  to  3  c.  c),  later  in  1  per  cent  solution  (6  to  7  c.  c). 

Eyall  ^  reports  having  used  novocain  with  the  addition  of  strychnin, 
according  to  the  Jonnesco  method. 

Chaput  ^  reports  405  cases  treated  with  novocain,  a  4  per  cent  solu- 
tion being  used,  without  addition.    The  dose  was  from  0.06  to  0.08  gm. 

Hypodermic  tablets,  novocain,  1/3  grain,  are  on  the  market.  Each 
tablet  contains  novocain  0.020  gm. 

In  988  of  my  1,065  cases  simple  solutions  of  the  analgesic  agent — 
eocain,  stovain,  tropacocain,  etc. — with  water,  were  employed.  In  the 
remaining  cases  I  have  used  various  modified  solutions,  heavier  and 
lighter,  with  and  without  the  addition  of  adrenalin  or  other  similar 
product.  With  no  intention  of  condemning  any  of  these  modified  solu- 
tions, I  must  confess  that  my  preference  is  decidedly  in  favor  of  the  sim- 
ple solution,  with  the  analgesic  agent  sterilized  according  to  the  method 
herein  detailed.  With  such  a  solution,  prepared  under  personal  super- 
vision, I  am  sure  of  the  fluid  injected  into  the  subarachnoid  space.  If 
it  were  possible,  as  with  Waugh,  Gray,  Barker,  Babcock,  and  those  who 
employ  the  ready-made  solutions,  to  obtain  the  modified  solutions  fresh 
and  dependable,  the  matter  would  be  different.  The  fact  remains,  how- 
ever, that  all  of  the  solutions  prepared  and  dispensed  in  ampules  deteri- 
orate with  time,  and  unless  one  is  convenient  to  the  source  of  supply 
there  is  always  a  doubt  concerning  the  potency  of  the  agent. 


STERILIZATION  OF  THE  ANALGESIC  AGENT* 

Many  of  the  unfortunate  results  obtained  in  the  early  history  of 
spinal  analgesia  were  presumably  due  to  improper  methods  of  sterilizing 
the  analgesic  agent.  This  was  certainly  true  of  eocain.  In  order  to 
overcome  this  difficulty  various  methods  of  sterilization  have  been  de- 
vised, of  which  those  of  Tuffier,  Roux,  Murphy,  and  Bainbridge  are  ex- 
amples. 

^  Meissner :     Beit.  Min.  Chir.,  64,  No.  1. 
=* Eyall:     Brit.  Med.  J.,  June  19,  1909. 
'Chaput:      Gaz.  des  Hopitaux,  1910,  No.  48. 
"See  Chapter  V  and  Chapter  XIII. 


SPINAL    ANALGESIA    AND     SPINAL    ANESTHESIA        605 

The  numerous  special  compounds  have  each  a  special  method  of 
preparation,  which  need  not  be  detailed  here. 

In  1899  the  following  method  ^  for  the  sterilization  of  cocain  was 
first  employed  by  me,  and  since  that  time  it  has  been  found  equally  satis- 
factory for  the  other  analgesic  agents  in  general  use.  The  simplicity  of 
the  procedure  renders  it  valuable  for  emergency  work,  as  well  as  for 
other  surgical  cases  in  which  spinal  analgesia  is  indicated. 

The  method  is  as  follows:  Five  grains  of  fresh  cocain  hydrochlorid 
crystals,  carefully  weighed,  are  placed  in  a  sterilized  measuring  glass. 
Two  drams  of  strong  ether  are  added,  and  mixed  thoroughly  with  the 
cocain  crystals  by  means  of  a  sterilized  glass  rod.  The  mixing  process  is 
continued  until  all  the  ether  is  evaporated.  One-half  to  1  ounce  of  warm 
boiled  or  filtered  water  or  normal  salt  solution  is  then  added.  One-half 
ounce  makes  practically  a  2  per  cent  solution,  and  1  ounce  a  1  per  cent 
solution.  Of  the  former  solution  10  to  20  minims  may  be  employed; 
of  the  latter,  10  to  30  minims. 

The  drug  is  practically  sterilized  in  its  manufacture,  and  all  that 
infects  it  is  apt  to  be  on  the  outside  of  the  crystals.  Careful  bacteriologi- 
cal tests  were  made  by  me  to  determine  the  extent  to  which  this  process 
sterilized  the  cocain,  and  it  was  found  that  practically  all  ordinary  organ- 
isms are  destroyed.     (See  Fig.  256,  p.  616.) 

The  crystals  do  not  deteriorate,  as  do  the  cocain  and  other  solutions. 
It  is  advisable,  however,  if  possible,  to  employ  only  fresh  crystals,  or  to  be 
sure  that  the  crystals  employed  have  been  kept  perfectly  dry. 

In  the  preparation  of  the  diffusible  solution  employed  by  Babcock 
pasteurization  is  resorted  to  instead  of  sterilization. 


SITES  OF  INJECTION 

The  routes  commonly  adopted  for  spinal  puncture  are  the  lumbar 
and  the  sacrolumbar,  the  former  being  preferable  in  human  beings  and 
the  latter  in  animals.  For  purposes  of  spinal  analgesia  the  points  of 
election  are  generally  conceded  to  be  between  the  spinous  processes  of 
the  third  and  fourth  or  fourth  and  fifth  lumbar  vertebrge.  It  is  easier 
to  enter  the  canal  at  these  sites,  and  the  danger  of  injury  to  the  cord  is 
minimized. 

Lusk  ^  emphasizes  the  conclusion,  drawn  from  a  series  of  anatomical 
studies,  that  "the  only  vertebral  interspaces  through  which  puncture  of 
the  subarachnoid  space  can  be  made  with  practical  assurance  that  nerve 
structure  will  not  be  penetrated  are  the  fourth  lumbar  and  the  lumbo- 
sacral, preferably  the  former." 

1  Bainbridge :     Op.  cit.,  Med.  Bee,  Dec.  15,  1900. 
2 Lusk:      Op.  cit.,  Ann.  of  Surg.,  Oct.,  1911. 


606 


ANESTHESIA 


According  to  this  author,  "The  anatomical  findings  in  eleven  dissec- 
tions of  the  arachnoid  membrane,  from  the  conns  medullaris  up  into  the 
cervical  region,  were  condemnatory  of  the  procedure  of  puncture  within 


Fig.  243.— Diagram  of  Cross-section  Opposite  the  Fourth;  Lumbar  Interspace. 
Below  the  lower  border  of  the  fifth  lumbar  vertebra  nerve-roots  were  adherent  to  the 
arachnoid.  Above  this  level  the  arachnoid  was  firmly  adherent  over  the  posterior 
surfaces  of  the  laterally  situated  nerve-roots  of  the  cauda  equina,  while  mesially  it  lay 
loosely  over  the  posterior  surface  of  the  nerve  structures,  to  which  it  was  connected  by 
delicate  trabeculse  from  about  one-eighth  to  one-quarter  inch  in  length,  the  shorter 
trabeculae  occupying  the  more  lateral  position.     (LuSk.) 

this  area,  as  one  attended  with  the  greatest  liability  of  penetrating  the 
cord." 


Fig.  244. — Diagram  of  a  Cross-section  Through  the  Dorsal  Spine.  Showing  how 
the  arachnoid  membrane  may  be  adherent  to  the  posterior  surface  of  the  cord,  which 
was  the  predominating  anatomical  arrangement  in  this  and  the  lower  cervical  regions 
in  six  out  of  ten  dissections.  The  close  contact  between  the  arachnoid  and  dura  is 
here  illustrated.     (Lusk.) 


In  fifteen  dissections  the  conus  medullaris  was  found  by  Lusk  to 
terminate  in  11  cases  at  the  level  of  the  first  lumbar  vertebra,  3  times 


SPINAL    ANALGESIA    AND    SPINAL    ANESTHESIA        G07 

at  the  level  of  the  junction  between  the  twelfth  dorsal  and  the  first  lum- 
bar vertebra,  and  once  it  reached  to  the  lower  border  of  the  second 
.lumbar  vertebra.  The  normal  or  usual  termination  is  shown  in  Figs. 
245  and  248. 

Of  11  dissections  of  the  arachnoid  membrane  above  the  conus,  in  only 
three  was  there  a  complete  posterior  arachnoid  space  present  all  the  way 
up  into  the  cervical  region,  the  channel  being  interrupted  at  intervals 
by  transverse  septa.  In  three  dissections  the  arachnoid  membrane  was 
adherent  to  the  posterior  surface  of  the  cord  all  the  way  from  the  conus 
up  to  the  cervical  region;  in  one  it  was  completely  adherent  above  the 
level  of  two  inches  above  the  conus,  and  in  two  above  the  levels  of  the 
fifth  and  seventh  dorsal  vertebrae  respectively.     ( See  Figs.  243  and  244. ) 

From  these  findings  Lusk  concludes  that,  if  the  cerebrospinal  fluid 
be  constantly  withdrawn  as  a  result  of  mesial  puncture  at  or  above  the 
level  of  the  conus,  in  many  instances  the  substance  of  the  cord  must  be 
traversed  by  the  needle  and  the  fluid  taken  from  the  anterior  portion  of 
the  arachnoid  space. 

In  all  the  15  dissections  Lusk  found  that  the  one  site  at  which  lum- 
bar puncture  of  the  arachnoid  space  could  have  been  made  without  lia- 
bility of  injury  to  the  nerve  roots  was  mesially  in  the  interval  between 
the  fourth  and  fifth  lumbar  vertebrae.  The  great  tendency  of  the  nerve 
roots  to  become  adherent  to  the  posterior  wall  of  the  arachnoid  sac  in  the 
lumbosacral  interspace,  as  well  as  for  the  subarachnoid  space  to  become 
shallower  in  this  region,  rendered  this  the  site  of  second  choice. 

Despite  the  anatomical  findings  of  Lusk  and  others  who  have  studied 
the  subject  from  this  point  of  view,  injections  have  been  successfully 
made  at  higher  levels  than  those  above  indicated. 

Morton,^  in  two  cases,  injected  between  the  last  dorsal  and  first  lum- 
bar, but  abandoned  this  site  as  being  unnecessary. 

Tait  and  Caglieri  -  (see  p.  561)  reported  having  injected  cocain  into 
the  sixth  cervical  space,  without  untoward  effects. 

Jonnesco,^  who  at  first  advocated  piercing  the  column  "at  all  levels," 
later  abandoned  this  procedure  and  confined  himself  to  two  sites :  .  ( 1 ) 
superior-dorsal,  between  the  first  and  second  dorsal  vertebrae,  and  (2) 
dorsolumbar,  between  the  twelfth  dorsal  and  first  lumbar  vertebrae.  "1 
had  already  been  convinced  by  experience,"  he  said,  "that  spinal  anes- 
thesia was  not  so  regional  as  I  had  believed,  and  that  mediocervical  punc- 
ture was  as  useless  as  it  was  dangerous.  It  favors  the  appearance,  of 
bulbar  phenomena — nausea,   vomiting,  pallor   of  the   face,   momentary 

^Morton:     Am.  Med.,  Aug.  3,  1901. 

='Tait  and  Caglieri:  Op.  cit.,  Trans,  of  the  Med.  Soc.  of  the  State  of  Cal., 
April,  1900;  also,  J.  Am.  Med.  Assn.,  July  7,  1900. 

^.lonnesco:  Brit.  Med.  J.,  Nov.  13,  1909;  also,  Hevue  de  therap.  med.-chir., 
Dec.  1,  1910,  798. 


Fig.  245. — Spinal  Cord  Enclosed  in 
Unopened  Dural  Sheath  Lying 
Within  Vertebral  Canal.  Neu- 
ral arches  completely  removed  on  right 
side,  and  partially  on  left,  in  order 
to  expose  dorsal  aspect  of  dura. 
(Piersol.) 


m 


<-jS1^ 


Fig.  24G. — Posterior  Wall  of  Verte- 
bral Canal  Has  Been  Removed  and 
Dural  Sheath  Opened  to  Expose 
Spinal  Cord  and  Dorsal  Roots 
OF     Attached    Nerves.        (Piersol.) 


SPINAL    ANALGESIA    AND    SPINAL    ANESTHKSIA 


G09 


stoppage  of  respiration,  and  so  on — phenomena  due  to  a  too  direct 
action  of  the  anesthetic  fluid  upon  the  bulb.  Tlieir  occurrence  may  be 
avoided  by  making  the  puncture  lower  down  between  the  first  and  sec- 
ond dorsal  vertebrae,  wliich  produces  as  perfect  and  rlccp  analgesia  for 


Anterior     roots    of 
spinal  nerves 


Dura,  reflected 


Spinal  cord  covered 
with  araohnoid  and 


Fig.  247. — Upper  Part  of  Spinal  Cord  Within  Dural  Sheath,  Which  Has  Been 
Opened  and  Turned  Aside.  Ligamenta  denticulata  and  nerve-roots  are  shown 
as  they  pass  outward  to  dura.     (Piersol.) 


610 


ANESTHESIA 


the  segment  of  the  hody  comprising  the  head,  neck,  and  upper  limbs  as 
is  produced  by  the  mediocervical  puncture.     I  have  therefore  reduced 

sites  of  election  for  puncture  or 
two."     These  are  stated  above. 

Canny  Eyall/  one  of  the 
most  enthusiastic  advocates  of 
the  Jonnesco  method  for  opera- 
tions upon  the  upper  part  of  the 
body,  makes  the  injection  into 
the  first  dorsal  space,  and  for 
operations  upon  the  lower  part 
into  either  the  eleventh  or 
twelfth  dorsal  spaces.  He  rarely 
uses  lumbar  puncture,  since,  in 
his  experience,  better  results  are 
obtained  by  making  the  injec- 
tion into  the  dorsal  region.  He 
finds  no  advantage  in  making 
a  cervical  puncture,  for  perfect 
analgesia  lasting  an  hour  or  two 
can  be  obtained  by  injecting  be- 
tween the  first  and  second  dor- 
sal spines. 

Gray  -  considers  it  unneces- 
sary to  make  the  puncture 
higher  than  the  interspace  be- 
tween the  first  and  second  lum- 
bar vertebrae,  the  space  between 
the  third  and  fourth  being  best 
for  routine  work. 

Avamresco  ^  varies  the  site 
of  puncture  according  to  the  op- 
eration, as  follows:  (1)  For 
operations  on  the  perineum,  ex- 
ternal genitals,  and  anus,  be- 
tween the  third  and  fourth  lum- 
bar vertebrae ;  (2)  for  operations 
on  the  inguinal  region  and  lower 


Fig.  248. — End  of  Spinal  Cord  With  Roots 
OF  Lower  Nerves  Descending  in 
Cauda  Equina  to  Gain  Their  Respec- 
tive Foramina.  (Piersol.) 


^  Eyall:  Op.  cit,  Brit.  Med.  J., 
June   19,    1909. 

-  Gray :  Op.  cit.,  Lancet,  Sept. 
25   and  Oct.  2,  1909. 

^Avamesco:  Lancet,  1901,  1,  637. 


Fig.  249. — Schematic  Picture  Showing  Landmarks  Used  In  Locating  Space  Between 
Third  and  Fourth  Lumbar  Vertebra. 


Fig.  250. — Schematic    Picture    Showing   Needle   Inserted   Between   Third   and 
Fourth  Lumbar  Vertebra  of  the   Spinal  Canal,   but  below  the   Cord. 


612  •  ANESTHESIA 

extremities,  between  the  first  and  second  lumbar  spines;  (3)  for  opera- 
tions on  the  abdomen  below  the  umbilicus,  between  the  ninth  and  tenth 
dorsal  spines;  (4)  for  operations  on  the  abdomen  above  the  umbilicus, 
between  the  sixth  and  seventh  dorsal  spines. 

Babcock  ^  injects  in  the  second  lumbar  interspace  for  operations  not 
involving  tissues  above  the  level  of  Poupart's  ligament,  or  the  first  lum- 
bar or  twelfth  dorsal  interspace,  if  intra-abdominal  manipulations  are 
required. 

Personally,  I  recognize  no  advantage  by  going  into  the  subarachnoid 
space  at  a  higher  point  than  between  the  third  and  fourth  lumbar  verte- 
bra, though  on  several  occasions,  because  of  deformity  of  the  spine,  or 
for  other  reasons,  the  spaces  between  the  first  and  second,  and  be- 
tween the  second  and  third  lumbar  vertebrae,  have  been  successfully  en- 
tered. In  cases  where  there  is  to  be  much  pulling  and  tearing  of  the 
tissues  of  the  abdomen,  particularly  in  the  upper  part,  I  sometimes  in- 
ject between  the  twelfth  dorsal  and  the  first  lumbar.  Analgesia  of  any 
part  of  the  body,  however,  may  be  obtained  by  lumbar  injection,  plus  the 
use  of  an  analgesic  agent  of  equal  or  lighter  specific  weight  than  the 
cerebrospinal  fluid,  or  by  employing  a  fluid  of  greater  specific  weight, 
plus  the  lowering  of  the  patient's  head. 

THE   PATIENT 

Preliminary  Preparation  of  Patient. — The  operator  who  is  to  make 
the  injection  should  apply  the  principles  of  psychotherapy  to  the  patient 
some  time  before  the  operation,  if  this  is  possible.  The  indications  for 
the  method  in  the  given  case  should  be  explained,  and  emphasis  laid  upon 
the  advantages  of  this  method  over  inhalation  anesthesia.  A  clear  un- 
derstanding of  what  is  to  be  expected  on  the  part  of  the  patient  is  quite 
conducive  to  the  successful  application  of  the  method.  At  any  rate,  the 
patient's  confidence  should  be  gained  by  the  operator.  This  is  particu- 
larly true  of  nervous  and  excitable  persons.  Even  with  children  much 
can  be  accomplished  in  this  way.  N'ot  infrequently  a  doll  or  other  toy 
put  into  the  hands  of  the  child  patient  will  divert  attention  and  gain 
confidence,  sometimes  rendering  an  otherwise  intractable  patient  quite 
docile. 

A  hypodermic  injection  of  morphin  (%  to  ^4  g^-)?  combined  in  some 
cases  with  atropin  or  hyoscin,  may  be  given  half  an  hour  or  an  hour  be- 
fore injection.  It  serves  to  tranquilize  the  patient  and  to  make  him  less 
susceptible  to  any  possible  pain  or  discomfort  contingent  upon  the  initial 
procedure.  Bromids  instead  of  morphin  may  be  given  the  day  before, 
or  nitroglycerin  (1/200-1/100  gr.),  given  coincidentally  with  the  spinal 
injection,  may  be  advantageous.    Strj^chnin  (1/60  gr.)  given  at  the  time 

^Babcock:      Op.   cit.,  Penn.  Med.   J.,' Aug.,   1909. 


SPINAL    ANALGESIA    AND    SPINAL    ANESTHESIA        G13 


of  the  injection  is  supportive.  Coml)inccl  with  nitroglycerin,  it  lessens 
the  danger  of  headache,  shock,  and  other  disagreeal)le  symptoms. 
No  preliminary  medication  is  given  with  children. 
Preliminary  prepara- 
tion of  the  patient  as  re- 
gards diet,  catharsis,  etc., 
which  is  of  so  great  im- 
portance in  inhalation 
anesthesia,  is  not  essen- 
tial in  spinal  analgesia. 
Patients  coming  into  the 
hospital  from  the  street, 
with  no  preliminary 
preparation  in  these  re- 
gards, have  been  oj^erated 
upon  as  successfully,  and 
with  as  few  accompany- 
ing and  postoperative 
phenomena,  as  have  those 
who  have  been  subjected 
to  the  most  careful  pre- 
paratory care.  Generally 
speaking,  however,  atten- 
tion to  no  details  which 
conserve  the  patient's  vi- 
tality and  comfort  should 
be  neglected. 

Position  of  Patient. 
— The  position  of  the  pa- 
tient while  the  injection 
is  being  made  is  impor- 
tant. One  should  sit 
evenly  on  the  edge  of  the 
table,  the  feet  hanging 
down.  The  arms  are 
folded  against  the  abdo- 
men. At  the  moment  of 
the  puncture  the  patient 
should  bend  the  head 
down,  as  in  Figure  259, 

and  push  against  the  abdomen  with  the  arms  in  such  way  as  to  arch  the 
back  and  separate  the  vertebrse  as  much  as  possible.  In  the  case  of  chil- 
dren and  infants,  it  is  necessary  for  the  attendant  to  see  that  this  position 
is  maintained. 


Fig.  251. — Patient  in  Sitting  Posture  Ready  foe 
Spinal  Puncture.  1  and  2,  Highest  points  of 
crests  of  ilia;  3,  spinous  processes  of  third,  fourth 
and  fifth  lumbar  vertebrse. 


614 


ANESTHESIA 


The  patient  must  be  warned  beforehand,  and  reminded  at  the  time, 
to  maintain  this  position,  and  not  to  straighten  up  or  otherwise  move 
until  told  to  do  so. 


Fig.  252. — Injection  Being  Made  With  Patient  in  Recumbent  Position. 

If  for  any  reason  it  is  impossible  to  make  the  puncture  with  the  pa- 
tient in  the  above  position,  it  may  be  done  in  the  recumbent  posture,  as 
shown  in  Figure  352. 


APPARATUS   AND   MATERIALS 

The  apparatus  and  materials  employed  in  the  induction  of  spinal 
analgesia  are  shown  in  Figures  253  and  254. 

The  apparatus  for  giving  the  injection  of  the  analgesic  agent  con- 
sists of  a  syringe  and  two  cannulas. 

The  syringe,  which  is  made  by  Ford  &  Co.,  of  New  York,  is  entirely 
of  metal,  including  the  piston,  so  that  it  expands  uniformly  upon  boil- 
ing. It  has  a  capacity  of  5  c.  c,  the  corresponding  quantities  in  the  two 
systems  being  graduated  upon  the  piston. 

The  cannula  are  made  in  two  sizes,  of  three  lengths;  the  points  are 
ground  short  and  beveled,  with  a  cutting  edge  all  round.  The  shank  is 
of  flexible  metal,  so  that  it  will  bend  without  breaking. 

The  cannula  slips  on  a  ground  joint,  fitting  accurately  the  handle, 
without  washers  or  screws.  The  proximal  end  of  the  cannula  is  fitted 
with  a  handle  which  can  be  firmly  grasped. 


■  SPINAL    ANALGESIA    AND    SPINAL    ANESTHESIA       615 

Through  the  cannula  runs  a  stylet,  the  proximal  end  of  which  is 
rounded,  knob-like,  so  that  it  can  be  pressed  against  the  base  of  the  index 
finger,  adding  firmness  of  grip. 


Fig.  253. — Table  Containing  Instruments  and  Materials  Used  in  Giving  Spinal 
Analgesia,  (a)  Glass  with  sterilized  water;  (b)  empty  glass  in  which  to  collect  cerebro- 
spinal fluid  (c)  bottle  of  iodin  for  sterilizing  the  skin ;  (d)  graduate  for  preparing  solu- 
tion; (e)  bottle  of  collodion;  (f)  bottle  of  ethyl  chlorid  wrapped  in  sterilized  gauze;  (g) 
sterilized  gauze  and  steriHzed  cotton;  (h)  small  can  of  strong  ether  wrapped  in  sterilized 
gauze;  (i)  dish  of  bichlorid  solution:  (j)  two  powders,  5  grains  each,  one  of  cocain  and 
one  of  tropacocain;  (k)  two  ampules  containing  stovain  (suprarenin-glucose  solu- 
tion) ;  (1)  two  needles  and  syringe  (Bainbridge) ;  (m)  small  scalpel  for  making  punc- 
ture; (n)  clamp  with  piece  of  sterilized  gauze  for  painting  the  skin  with  iodin;  (o)  glass 
rod  for  mixing. 

The  instrument  can  be  taken  apart  and  thoroughly  sterilized. 
Figure  255  shows  the  fine  needle  employed  by  Babcock.    The  syringe 
is  a  Luer  syringe  of  2  c.  c.  capacity,  graduated  in  cubic  centimeters  and 


Fig.    254 — Bainbridge's  Syringe  and  Needle. 


Fig.  255. — Babcock's  Needle  for  Spinal  Analgesia. 


millimeters.  The  obturator  which  comes  with  this  needle  fits  perfectly 
around  the  opening  at  the  end  of  the  needle,  thereby  closing  it  entirely 
during  the  time  it  is  being  injected  and  until  the  obturator  is  withdrawn, 


F  G 

Fig. -256. — Sterilizing  the  Apparatus.  A,  placing  the  drug  in  the  graduate;  B,  adding  ether 
to  sterilize;  C,  mixing  ether  with  powder  into  a  paste;  D,  adding  required  amount  of  water 
to  make  given  solution;  E,  testing  syringe  with  sterile  water;  F,  testing  syringe;  G,  filling 
syringe  with  injection  material. 


SPINAL    ANALGESIA    AND     SPINAL    ANESTHESIA        617 

before  the  syringe  is  slipped  into  the  hub  for  the  injection  of  the  analgesic 
agent.     This  needle  is  made  by  Charles  Lentz  &  Sons,  Philadelphia. 

In  sterilizing  the  apparatus  no  soda  or  other  alkalies  sliould  be  era- 
ployed,  nor  should  the  analgesic  agents  be  in  any  way  allowed  to  come 
in  contact  with  these  substances,  which  destroy  tlieir  analgesic  properties. 

The  sterile  implements  and  materials  are  placed  upon  a  table  covered 
with  a  sterile  sheet  until  ready  for  use. 

Various  needles,  syringes,  etc.,  have  been  devised  and  advocated,  and 
are  readily  obtainable.  The  apparatus  described  above  will  answer  all  re- 
quirements of  spinal  analgesia. 


TECHmauE  or  injection 


The  operator's  hands  are  made  aseptic  in  the  usual  manner. 

The  site  of  puncture  may  be  cleansed  in  the  ordinary  Avay,  by  scrub- 
bing, etc.,  or,  if  desired,  it  may  be  rendered  aseptic,  after  the  patient  has 
been  placed  upon  the  table,  by  painting  the  skin  with  tincture  of  iodin. 
If  preferred,  the  area  may  be  painted  an  hour  or  so  before  operation,  and 
again  after  the  patient  is  placed  upon  the  table. 

If  the  iodin  method  is  employed,  no  preliminary  washing  should  be 
resorted  to  unless  it  is  done  a  sufficiently  long  time  before  the  painting 
for  the  tissues  to  become  thoroughly  dry.  If  desired,  the  skin  may  be 
sponged  with  ether,  which  quickly  evaporates,  leaving  a  perfectly  dry 
surface  for  the  action  of  the  iodin.  This  is  not  necessary,  however,  as 
the  iodin  is  sufficient  for  purposes  of  antisepsis. 

The  patient,  in  the  position  shown  in  Figure  351,  with  the  puncture 
site  painted  with  iodin,  as  shown  in  Figure  257,  is  draped  with  the 
sterilized  sheet,  as  shown  in  Figure  258. 

This  sheet  has  cut  in  it  a  hole  or  window  (Fig.  258)  large  enough  for 
purposes  of  injection.  The  oi3erator,  in  making  his  examination  and 
identification  of  landmarks,  runs  no  risk  of  contaminating  his  hands 
by  contact  with  skin  surfaces  which  have  not  been  rendered  aseptic. 

The  site  of  puncture  is  now  located  in  the  following  manner,  as  indi- 
cated in  Figures  259,  2G0,  and  261: 

(1)  The  highest  points  on  the  crests  of  the  ilia  are  located  by  the 
hands,  as  shown  in  the  figures. 

(2)  The  sites  of  the  second,  third,  fourth,  and  fifth  lumbar  verte- 
brae are  marked. 

(3)  The  thumb  of  each  hand  is  placed  in  the  space  between  the  sec- 
ond and  third,  third  and  fourth,  or  fourth  and  fifth  lumbar  vertebrae. 


618 


ANESTHESIA 


according  to  the  selection  of  site,  at  the  mid-point  between  the  two.    One- 
half  inch  to  either  side  of  this  point  is  the  site  for  the  puncture. 

The  puncture  point  being  located,  the  assistant  plays  ethyl  chlorid  on 

the  area,  or,  if  preferred, 
a  preliminary  injection 
of  cocain  or  other  local 
analgesic  agent  may  be 
made.  (See  Fig.  360.) 
A  small  incision  is 
now  made  through  the 
true  skin,  which  is  ren- 
dered hemostatic  as  well 
as  analgesic  by  the  ethyl 
chlorid. 

The  needle  is  passed 
through  the  incised  skin 
and  subcutaneous  tissue, 
straight  forward,  as  in 
Figures  250  and  361.  It 
is  then  depressed,  the 
point  being  made  to  go 
upward,  forward,  and  in- 
ward, toward  the  median 
line.  It  is  inserted  from 
11/^  to  3  inches,  accord- 
ing to  the  thickness  of 
the  patient's  flesh. 

When  the  needle  is 
felt  to  impinge  upon  the 
bone  surrounding  the 
foramen,  it  is  depressed 
a  little  more,  and  pushed 
forward,  when  it  comes 
upon  the  ligamentum 
subflavum,  then  the  dura 
mater.  In  piercing  the 
ligament  and  dura  there 
is  a  peculiar  sensation 
like  the  popping  of  a  membrane.  This  signifies  the  entrance  to  the  sub- 
arachnoid space. 

The  cerebrospinal  fluid  escapes,  as  shown  in  Figure  363,  under  ordi- 
nary circumstances.  If  it  does  not  flow  freely,  something  is  wrong.  The 
needle  may  not  have  entered  the  right  place,  or  it  may  be  clogged.  A 
stylet  should  not  be  inserted  into  the  needle.    Another  syringe  should  be 


Fig.  257. — Puncture  Site  Area  Painted  with  Iodin. 


SPINAL    ANALGESIA    AND    SPINAL    ANESTHESIA        619 


ready,  and  with  this,  if  one  cannot  draw  out  blood  or  fluid,  the  needle 
should  be  withdrawn,  and,  after  being  rendered  patent,  be  reinserted. 

It  should  be  noted  that  there  is  considerable  difference  in  spines  with 
reference  to  the  amount  of 


cerebrospinal  fluid,  some 
being  what  is  called  "dry," 
with  little  fluid  escaping 
upon  puncture ;  others, 
"wet,"'  with  an  abundance 
of  fluid  under  high  tension. 
The  quantity  withdrawn  de- 
pends upon  the  tension.  If 
the  fluid  comes  out  with 
force  more  is  withdrawn 
than  when  it  is  not  under 
much  pressure. 

I  prefer  not  to  proceed 
with  the  injection  unless 
the  fluid  issues  with  at 
least  an  approximate  quan- 
tity and  tension.  Gray  ^ 
does  not  hold  to  this  point. 
Discussing  the  general 
opinion  that  satisfactory 
analgesia  will  not  result  un- 
less there  is  a  free  flow  of 
fluid,  he  says: 

"This  is  true  enough  in 
the  main,  but  if,  after  pa- 
tience and  perseverance,   a 
free  flow  of  fluid  cannot  be 
obtained,     but     only     slow 
drops  (oT  if  slightly  blood- 
stained fluid  only  appears), 
I   consider  that  the   injec- 
tion should  be  attempted  before   making  another  puncture,   provided 
cerebrospinal  fluid  has  been  seen.     I  have  encountered  this  class  of  case 
on  two  or  three  occasions,  when,  in  spite  of  failure  to  obtain  a  free  jet,  a 
perfectly  satisfactory  anesthesia  has  resulted  from  the  injection." 

Donitz  ^  and  Dean  ^  suggest  that  when  the  fluid  flows  scantily  this  is 
an  indication  for  a  larger  quantity  of  the  analgesic  solution. 

^Gray:     Op.  cit.,  Lancet,  Sept.  25,  Oct.  2,  1909. 

^  Verhandl.  d.  deuisch.   Gesellsch.  f.   Chir.,   1905,   525-548. 

^Brit.  Med.  Jour.,    1907,  2,   869. 


Fig.   258. — Sterilized   Sheet,   Patient  Draped, 
AND  Window  Made  at  Site  of  Puncture. 


Fig.  259. — Locating  the  Site  for  Puncture. 


Fig.  260. — Applying  Ethyl  Chlorid  and  Incising  the  Skin. 


SPINAL    ANALGESIA    AND    SPINAL    ANESTHESIA        621 

In  some  cases,  despite  careful  technique  and  repeated  attempts,  at 
different  sites,  no  cerebrospinal  fluid  is  obtainable.  Such  cases  have 
doubtless  led  to  the  expression  "dry  spinp,"  but  it  is  rather  to  be  in- 
ferred that  they  come  under  the  category  mentioned  by  Gerstenberg  and 
Hein,  Lusk,  and  others.  (See  pp.  564  and  605  et  seq.)  A  personal  ex- 
perience with  such  a  case  is  cited  on  page  624. 

The  first  few  drops  of  fluid  may  be  bloody,  which  may  signify  merely 
that  a  small  quantity  of  blood  has  been  carried  in  with  the  needle.     If  it 


Fig.  261. — Showing  Direction  of  Needle  About  to  Enter  Spinal  Canal. 


continues  bloody,  however,  something  more  serious  is  to  be  considered. 
This  rarely  happens,  but  when  it  does  the  operation  should  be  discon- 
tinued. 

Sometimes,  when  the  fluid  does  not  flow  freely,  it  will  do  so  if  the 
patient  will  cough,  thus  causing  more  tension  upon  it. 

An  uncontrollable  patient,  who  will  not  remain  still  and  quiet,  should 
be  held  steadily  while  the  puncture  is  being  made,  or  the  needle  should  be 
withdrawn  at  once.  The  injection  of  the  analgesic  agent  should  not  be 
made  unless  the  patient  is  perfectly  quiet. 

The  fluid  is  injected  slowly,  as  shown  in  Figure  263.  The  obliquity  of 
the  passage  of  the  needle  has  the  advantage  that  no  tract  is  formed  for 
the  fluid  to  follow  as  the  needle  is  withdrawn. 

The  body  of  the  vertebra  in  front  should  not  be  touched  with  the 
needle,  because  of  the  presence  there  of  a  large  plexus  of  blood  vessels. 


622 


ANESTHESIA 


Fig.  262. — Cerebrospinal  Fluid  Escaping. 


When  the  needle  is  withdrawn  a  cotton  and  collodion  dressing  is  ap- 
plied, as  shown  in  Figure  264. 

If  low  analgesia 
is  desired,  for  op- 
eration upon  the 
lower  part  of  the 
body,  the  patient 
may  be  allowed  to 
sit  up  for  a  few 
minutes  after  the 
injection,  or  the 
head  may  be  ele- 
vated. 

If  high  anal- 
gesia through  lum- 
bar puncture  is 
desired,  for  opera- 
tions upon  the  up- 
per part  of  the 
body,  the  head  is 
lowered,  or  a  fluid 
with  lower  specific  gravity  than  the  cerebrospinal  fluid  is  employed. 
Having  had  no  personal  experience  with  the  Jonnesco  method  of  induc- 
ing high  analgesia,  no 
statement  can  be 
made  with  reference 
to  the  relative  merits 
of  the  so-called  high 
analgesia  for  this  pur- 
pose, as  compared 
with  lumbar  injection 
plus  modified  agent  or 
position  of  patient. 

Babcock  ^  prefers 
to  use  a  small  needle 
(Fig.  255),  and  to  go 
in  without  the  pre- 
liminary nicking  of 
the  skin.  If  the  pa- 
tient has  received  no 
preliminary  medica- 
tion the  area  marked 
off  on  the  back  is  frozen  by  a  spray  of  ethyl  chlorid.    The  needle  is  intro- 

» Babcock:      Op.  cit.,  Penn.  Med.  J.,   Aug.,  1909. 


Fig.  263. — Injecting  Solution. 


SPINAL    ANALGESIA    AND    SPINAL    ANESTHESIA 


623 


duced  through  the  line  marking  the  injection  point,  at  right  angles  to 
the  skin,  and  about  2  millimeters  to  one  side  of  the  median  line.  The 
needle  is  carried  steadily  forward  until  the  resistance  of  the  ligamontum 
subflavum  is  felt,  when  the  mandrin  is  withdrawn  from  the  needle,  which 
is  then  carried  on  through  the  dura. 

If  high  analgesia  is  desired,  Babcock  considers  it  advisable,  before  the 
injection  is  given,  to  so  reduce  the  cerebrospinal  fluid  that  it  issues  only  in 
drops  from  the  needle.  The  needle  is  cautiously  rotated  to  make  sure  that 
the  bevel  point  is  en- 
tirely through  the  mem- 
brane. The  syringe  is 
then  attached,  and  about 
1  c.  c.  of  cerebrospinal 
fluid  is  cautiously  with- 
drawn to  mix  with  and 
dilute  the  analgesic  so- 
lution. The  mixture  is 
now  steadily  and  rather 
rapidly  injected,  the 
needle  with  the  attached 
syringe  quickly  with- 
drawn, and  the  patient 
immediately  placed  in 
the  recumbent  posture 
with  the  head  slightly 
raised.  This  last  point 
is  of  the  utmost  im- 
portance. 

In  testing  for  analgesia,  which  begins  in  from  three  to  ten  minutes 
after  the  injection,  one  should  bear  in  mind  the  difference  between  anal- 
gesia and  anesthesia.     (See  Introduction,  p.  555.) 


Fig. 


264. — Cotton   and    Collodion    Dressing   on 
Puncture  Point. 


ADDITIONAL  ILLUSTRATIVE  CASE  REPORTS 


With  the  preliminary  preparation,  the  necessary  adjuvant  medica- 
tion, and  the  careful  technique,  as  outlined  in  the  foregoing  pages,  there 
should  be  no  difficulty  with  spinal  analgesia,  unless  some  anatomical 
anomaly  or  an  idiosyncrasy  be  encountered.  Occasionally, — very  rarely, 
— one  encounters  a  patient  who  possesses  an  idiosyncrasy  with  refer- 
ence to  one  or  another,  or  perhaps  all,  of  the  spinal  analgesic  agents. 
Such  a  case  was  encountered  by  me  recently,  as  was  also  one  of  so-called 
"dry  spine.' 

Case  of  Idiosyncrasy. — H.  C,  female,  aged  24.  Consulted  me  in  Feb- 
ruary, 1911,  with  reference  to  hernia  and  displacement  of  the  uterus.    Pa- 


624  ANESTHESIA 

tient  was  anemic  and  nervous,  and  had  an  old  healed  tuberculous  lesion 
of  the  lung.  Otherwise  in  fair  general  condition.  She  requested  that 
operation  be  performed  under  spinal  analgesia.  This  was  undertaken  on 
February  lA,  1911,  no  preliminary  medication  being  employed. 

Spinal  puncture  was  made,  between  the  third  and  fourth  lumbar 
vertebrae,  and  30  minims  of  fluid  withdrawn.  An  injection  was  made  of 
15  minims  of  a  3  per  cent  solution  of  novocain.  After  an  interval  of  15 
minutes  there  was  no  analgesia,  even  in  the  feet.  A  second  injection 
was  made,  this  time  with  stovain,  13  minims  of  a  3  per  cent  solution 
being  used.  After  waiting  20  minutes  the  site  of  operation  was  still 
sensitive.  During  all  this  time  (40  minutes  from  the  time  of  the  first  in- 
jection), the  patient  was  in  good  condition,  with  only  slight  nausea  and 
no  vomiting.    The  pulse  was  120,  full  and  strong. 

The  operation  was  abandoned  for  the  day,  it  being  thought  unwise  to 
subject  the  patient  to  a  third  injection.  During  the  next  three  days 
she  suffered  from  slight  headache,  but  was  otherwise  in  good  condition. 

On  February  17  another  attempt  was  made  to  induce  spinal  anal- 
gesia. Cocain  was  used  on  this  occasion,  15  minims  of  a  2  per  cent  solu- 
tion being  employed.  After  25  minutes  there  was  no  evidence  of  anal- 
gesia so  far  as  pain  sense  was  concerned.  The  patient  was  nervous  to 
begin  with,  and  became  nauseated  after  the  injection,  but  the  pulse  (120) 
was  fairly  strong.  A  second  attempt  was  made,  but,  as  there  was  no  es- 
cape of  fluid,  no  injection  was  made. 

On  the  assumption  that  the  patient  had  an  idiosyncrasy,  it  was  de- 
cided to  test  the  matter  with  local  injections.  ^Accordingly,  1  c.  c.  of  a 
2  per  cent  solution  of  cocain  was  injected  at  the  site  of ' operation,  but 
without  success.  The  patient  became  quite  hysterical,  and  the  entire  mat- 
ter was  abandoned.  Patient  was  subsequently  operated  upon  under  gen- 
eral anesthesia. 

Upon  further  questioning,  it  was  learned  from  the  patient  that  in 
1900  an  attempt  was  made  by  Dr.  Frederick  Kammerer,  of  New  York, 
to  operate  upon  her  for  appendicitis  under  spinal  analgesia,  cocain  being 
employed.  No  analgesia  was  obtained,  and  the  operation  was  performed 
under  general  anesthesia. 

Case  of  So-called  ''Dry  Spine." — B.  M.,  female,  negro,  aged  17.  Oper- 
ation, Woman's  Hospital,  Philadelphia,  January  25,  1912,  appendectomy. 
Gangrenous  appendix  found  to  be  walled  off  by  adhesions.  Kecovery  un- 
eventful. 

This  patient  had  Bright's  disease  and  an  old  consolidation  at  the  apex 
of  one  lung.  For  these  reasons  it  was  thought  advisable  to  operate  under 
spinal  analgesia. 

An  attempt  was  made  to  operate  in  this  case  under  spinal  analgesia, 
but  without  success.  Puncture  was  made  between  the  fourth  and  fifth 
lumbar  vertebrae,  but,  only  a  tiny  drop  of  fluid  being  obtained,  injection 


SPINAL    ANALGESIA    AND    SPINAL    ANESTHESIA        625 

was  not  made.  A  second  attempt  with  another  needle  proving  futile, 
puncture  was  made  successively  in  the  spaces  between  the  third  and 
fourth  and  second  and  third  lumbar  vertebra;.  No  fluid  being  obtained, 
the  efl^ort  at  spinal  analgesia  was  abandoned,  and  the  operation  was  per- 
formed under  inhalation  anesthesia. 

Case  of  a  Typical  "Satisfactory"  Analgesia.^ — L.  L.,  female,  aged  58, 
admitted  to  the  New  York  Skin  and  Cancer  Hospital,  March  18,  1911, 
for  operation  for  lipomata  of  the  abdominal  wall,  papilloma  of  neck, 
angiomata  of  abdominal  wall,  and  varicose  ulcers  of  the  legs.  Opera- 
tion, March  20,  1911.  The  various  growths  were  removed,  and  the  ul- 
cers of  the  legs  excised. 

Adjuvant  medication :  Strychnin  sulphate,  1/GO  gr. ;  nitroglycerin, 
1/200  gr. 

Analgesic  agent :  Glucose-adrenalin-stovain,  one  ampule,  2  c.  c. ; 
stovain,  3  per  cent. 

Analgesia  extended  to  neck,  and  lasted  for  1  hour  and  55  minutes. 

There  was  no  nausea,  no  vomiting,  no  headache,  or  other  unfavorable 
symptom,  and  recovery  was  uninterrupted. 

Case  of  Typical  Analgesia,  hijection  in  Recumhent  Position. — Fig- 
ure 262  represents  the  injection  being  given  with  the  patient  in  the 
recumbent  position.  This  patient  was  a  male,  B.  N.,  aged  38  years. 
Operated  upon  for  gangrene  of  the  foot  February  7,  1911,  the  foot  being 
partially  amputated. 

No  preliminary  medication.  Stovain,  8  minims  of  a  3  per  cent  solu- 
tion, injected  between  the  third  and  fourth  lumbar  vertebrae.  Analgesia 
complete  to  the  umbilicus  in  8  minutes.    No  unfavorable  symptoms. 

On  February  24,  1911,  amputation  of  foot,  leaving  os  calcis.  Sixteen 
minims  of  a  3  per  cent  solution  of  stovain  in  water  employed.  Within 
2  minutes  after  the  injection  the  patient  was  analgesic  to  the  nipple  line, 
and  5  minutes  after  the  injection  the  operation  was  begun.  No  unfavora- 
ble symptoms.    Patient  manifested  an  interest  in  the  entire  procedure. 

An  Additional  Case  (No.  1069),  of  Special  Interest.^ — During  the 
Clinical  Congress  of  Surgeons  of  North  America,  held  in  New  York  City 
in  November,  1912,  a  patient  at  the  New  York  Polyclinic  Hospital  died 
after  a  lumbar  subarachnoid  injection  of  stovain,  preparatory  to  the  per- 
formance of  an  operation  for  hernia. 

P.  H.,  Irish,  male,  age  given  as  50  years,  probably  60  or  more;  chronic 
alcoholic.  Came  to  my  clinic  at  the  New  York  Polyclinic  Medical  School 
and  Hospital,   October  18,  1912,  seeking  relief  for  a  condition  which 

^  This  is  the  case  with  which  the  technique  is  illustrated,  Figs.  251  and  257 
to  264. 

^  Bainbridge :  ' '  Spinal  Analgesia — Development  and  Present  Status  of  the 
Method,  with  a  Brief  Summary  of  Personal  Experience  in  1,065  Cases."  J. 
Am.  Med.  Assn.,  Nov.  23,  1912,  59,  1855-1859. 


626  ANESTHESIA 

proved,  upon  examination,  to  be  right  inguinal  hernia,  at  times  irreduci- 
ble, and  causing  great  suffering.  The  man  gave  a  history  of  having  felt  a 
sharp,  tearing  pain  in  the  right  groin,  while  operating  a  taxicab,  about 
three  months  previous  to  coming  to  the  clinic.  Since  that  time  he  had 
been  to  several  dispensaries  in  a  vain  search  for  relief.  He  had  used  a 
truss  without  success.  Failing  to  obtain  relief  by  other  measures,  he 
wished  to  be  operated  upon  at  once. 

From  the  general  physical  examination  the  patient  was  found  to  be 
in  a  very  bad  condition,  as  the  result  of  the  prolonged  excessive  use  of 
alcoholic  stimulants.  The  following  conditions  were  present:  general 
atheroma  of  the  arteries ;  renal  insufficiency,  due  to  chronic  Bright's  dis- 
ease; marked  enlargement  of  the  liver;  myocarditis,  with  systolic  mur- 
mur at  the  base ;  emphysema ;  rales  over  the  bases  of  both  lungs.  A  his- 
tory of  chronic  gastritis  was  also  elicited. 

The  patient's  general  condition  was  such  that  immediate  operation 
was  not  deemed  advisable.  He  was  told,  accordingly,  to  abstain  from  the 
use  of  intoxicants,  and  to  refrain  from  lifting  or  straining;  he  was  put 
upon  a  diet,  tonics,  etc.,  and  was  kept  under  observation  for  about  three 
weeks.  Despite  the  fact  that  only  slight  improvement  followed  this 
regime,  he  insisted  upon  operation.  He  was  then  admitted  to  the  hos- 
pital on  jS"ovember  14,  and  prepared  for  operation  the  next  day. 

Because  of  the  man's  general  condition,  inhalation  anesthesia  was  con- 
sidered contraindicated.  He  was  prepared,  accordingly,  for  operation 
"imder  spinal  analgesia.  Before  the  members  of  the  Congress  of  Surgeons 
present,  I  injected  into  the  cauda  equina  twenty-six  minims  of  a  one  per 
cent  solution  of  stovain.  The  patient,  who  presented  no  symptoms  differ- 
ing from  those  of  the  average  subject  during  the  spinal  injection,  was 
then  sent  to  another  room  to  be  operated  upon  by  E.  M.  Foote  and  Claude 
A.  Frink,  of  my  staff,  while  I  concluded  my  lecture  before  the  Congress. 
The  man's  mind  was  perfectly  clear,  his  pulse  was  good,  there  was  no 
nausea,  no  cyanosis,  no  respiratory  embarrassment — in  fact,  none  of  the 
symptoms  of  stovain  jmsoning.  He  suddenly  turned  pale,  said,  "I  am 
dying,"  and  instantly  died. 

The  case  was  made  a  coroner's  case,  and  an  autopsy  was  performed 
the  next  day,  with  the  following  findings : 

Marked  edema  of  the  brain,  so-called  "wet  brain";  myocarditis; 
atheroma  of  aorta;  aortic  insufficiency;  emphysema  of  lungs;  chronic 
interstitial  splenitis ;  chronic  gastritis ;  chronic  enteritis ;  chronic  intersti- 
tal  nephritis.     Spinal  cord  showed  no  gross  lesion. 

The  coroner's  inquest  was  held  on  December  4,  1912.  The  jury,  after 
listening  to  the  testimony  of  the  above  facts  and  a  number  of  experts  as 
to  the  indications  of  death  by  stovain  poisoning,  did  not  find  that  the 
man  died  of  stovain  poisoning,  but  that  death  was  caused  "by  pathological 
conditions"  as  described,  and  all  concerned  were  exonerated  from  blame. 


SPINAL    ANALGESIA    AND    SPINAL    ANESTHESIA        627 

CONCLUSION 

In  summing  up  the  entire  subject  of  spinal  analgesia,  the  author  of 
this  section  wishes  to  reiterate  that  this  method  is  not  to  be  considered  as 
replacing  inhalation  anesthesia.  It  has,  however,  a  distinct  place  in  sur- 
gery, and  as  the  indications  and  contraindications  are  more  clearly  un- 
derstood and  the  technique  of  the  method  improved,  its  field  of  useful- 
ness has  widened,  and  will  doubtless  continue  to  widen.  It  must  never- 
theless still  occupy  a  limited  sphere  until  further  accurate  and  scientific 
experimentation  has  led  to  more  certain  conclusions  with  reference  to  the 
physiological  action  of  the  agents  employed  and  the  dosage  in  which  they 
may  be  used  to  obtain  a  given  result. 


CHAPTEE    XVI 

ELECTEIC  ANALGESIA,  SLEEP,   AND   EESUSCITATION 

Louise  G.  Eobinovitch,  B.  es  L.,  M.  D.  (Paris) 

History:  Electric  Source  and  Technique;  Application  in  Man; 
Contraixidications ;  Electric  Analgesia  and  Sleep  in  Wireless  Circuits; 
Conclusions. 

Electric  Analgesia  and  Electric  Eesuscitation  After  Heart 
Failure  Under  Chloroform  or  Electrocution  :  Exclusion  of  the 
Head;  Kind  of  Current  Used;  Procedure;  Limitations;  Application  in 
Accidental  Electrocution;  Application  in  Surgery;  Clinical  Applica- 
tions. 

History. — In  1890  d'Arsonval  found  that  high  frequency  currents 
above  3,500  and  not  over  10,000  periods  per  second  caused  a  certain  degree 
of  anesthesia.  In  1892,  or  earlier,  Hutchinson  found  that  induction 
currents,  frequently  interrupted  with  the  ribbon  vibrator  that  he  had 
invented,  caused  anesthesia.^  In  1901  Mile  Pompilian  produced  anes- 
thesia in  frogs  by  subjecting  them  to  induction  currents  frequently 
interrupted  by  means  of  a  revolving  wheel  with  12  insulated  segments 
designed  by  herself.^  In  1902  Leduc  and  Eouxeau  experimented  with 
direct  currents  interrupted  by  means  of  a  revolving  wheel  designed  by 
them.  This  wheel  had  4  insulated  segments.^  There  were  2  contact 
levers;  one  lever  was  fixed  and  the  other  adjustable.  By  changing  the 
relative  position  of  the  movable  level  it  was  possible  to  change  the  period 
of  the  passage  of  the  current.  One-tenth  of  the  entire  period  during  a 
revolution  was  found  to  be  the  most  favorable  condition  for  producing 
what  was  then  called  electric  "sleep"  or  "anesthesia." 

In  1905  we  found,  while  working  in  the  laboratories  of  these  two  pro- 
fessors, that  an  induction  current  obtained  by  an  induction  apparatus  in 
which  the  primary  coil  was  run  by  means  of  a  frequently  interrupted  di- 
rect current,  6,000  times  per  minute,  period  1/10,  produced  deep  anesthe- 

^  Verbal  information  given  by  the  New  York  manufacturers  of  coils  with  the 
ribbon  vibrator. 

^  Personal   communication. 

^  Rouxeau  did  not  know  of  the  existence  of  Mile  Pompilian 's  models  when  he 
designed  his  wheel. 

628 


ELECTRIC   ANALGESIA,   SLEEP,   AND   RESUSCITATION    629 

sia  in  rabbits.  While  working  out  the  details  of  the  physiology  of  electric 
"anesthesia"  we  pointed  out  the  dangers  of  using  induction  currents  on 
animals,^  especially  when  the  head  was  included  in  the  circuit.  In  1900 
researches  into  the  blood  pressure,  temperature,  respiration,  and  duration 
of  electric  "sleep,"  as  well  as  studies  of  the  effects  of  the  two  polarities 
and  of  various  electric  currents,  were  conducted.  In  1907-1908  we  per- 
fected the  interrupter,  general  instrumentation,  and  technique  of  appli- 
cation.^  In  1909  we  pointed  out  that  a  certain  degree  of  analgesia  and 
sleep  could  be  obtained  in  rabbits  with  currents  generated  by  a  Vreeland 
oscillator,  the  preferred  form  of  current  being  a  pulsating  one.^ 

In  December,  1909,  we  found  that  "sleep"  could  be  produced  by  uni- 
polar and  even  by  wireless  methods  in  paths  of  displacement  currents.  In 
1910  we  obtained  myogram  traces  showing  muscle-nerve  reaction  in  paths 
of  displacement  currents  by  both  the  unipolar  and  wireless  method.  After 
we  had  registered  these  myogram  traces.  Law  found  a  valuable  reference 
to  Danilevsky's  remarkable  experiments  on  muscle-nerve  reaction  in  the 
vicinity  of  powerful  electromagnetic  fields.* 

The  first  physiological  investigations  on  electric  sleep,  or  anesthesia, 
were  made  by  Rouxeau.^  The  detailed  physiologic  researches  into  this 
sleep  and  anesthesia  were  made  by  us  in  his  laboratory.  Utilization  of 
this  anesthesia  in  laboratory  surgery  was  made  in  1906.  To  eliminate 
the  muscular  rigidity  caused  by  the  earlier  models  of  interrupter,  we  per- 
fected the  wheel  interrupter  and  pointed  out  the  danger  of  using  the  city 
current,  alternating,  rectified,  ordinary  wet  battery,  and  all  sorts  of  ir- 
regular currents.^  In  1907  we  employed  electric  sleep  and  anesthesia  in 
clinical  work,'^  and  electric  analgesia  was  applied  by  us  locally  in  1910. 

^  Eobinovitch :  ' '  Sommeil  electrique,  epilepsie  electrique  et  electrocution, ' ' 
These,  Paris,  1906. 

^Kobino witch:  "Electric  Anesthesia  or  Sleep,"  HandbooJc  of  Med.  Sci., 
N.  Y.,  1907;  "Electric  Anesthesia;  Its  Use  in  Laboratory  Work,"  J.  Kent. 
Path.,  1907,  No.  3. 

*  Eobinovitch :  "Physiologic  Effects  of  a  New  Variety  of  Electric  Current," 
J.  Ment.  Path.,  1909,  No.  4;  also,  Med.  Bee,  Dec.  11,  1909,  1009.   -^ 

*  Danilevsky :  ' '  De  1  'excitation  des  nerf  s  par  les  rayons  electriques, ' '  Compt. 
rendu  du  XXIIeme  Cong.  Inter,  de  Med.,  Moscow,  Aug.,  1847,  59. 

^  Leduc  and  Eouxeau :  ' '  Du  temps  pendant  lequel  peut-etre  maintenu  1  'etat 
du  sommeil  electrique,"  Compt.  rend.  d.  I.  Soc.  d.  Biol.,  July  4,  1903;  also,  "De 
1  'influence  du  rhythme  et  de  la  periods  sur  la,  production  de  1  'inhibition  par  les 
courants  intermittents  de  basse  tension." 

®  Eobinovitch :  ' '  Electric  Anesthesia,  Its  Use  in  Laboratory  Work, ' '  J. 
Ment.  Path.,  1907,  No.  3;  also,  "Anesthesie  electrique;  application  elinique;  pre- 
sentation de  malades  et  d  'instruments, ' '  Bull.  d.  I.  Soc.  Clinique  d.  Med.  ment., 
Nov.,  1908,  No.  4;  also,  "Motor-interrupter  Supplying  a  Current  of  Frequent 
Interruption  for  Electric  Anesthesia,"  Bull.  d.  I.  Soc.  Clinique  d.  Med.  ment., 
Nov.,  1908. 

'  Eobinovitch :  * '  Electric  Anesthesia  in  Laboratory  Surgery  Successfully  Ap- 
plied During  a  Period  of  Three  Years.    Demonstration  on  an  Animal  and  Clinical 


630  ANESTHESIA 

Electric  Source  and  Technique. — Pending  further  investigation  of 
our  findings  and  practical  application  of  wireless  electricity  for  producing 
sleep  in  man,  we  shall  go  over  the  matter,  dealing  with  currents  in  wired 
circuits  in  relation  to  sleep  and  analgesia,  as  we  have  applied  it  in  clinical 
work  as  well  as  in  animal  and  in  human  surgery. 

Nothing  but  storage  batteries  of  large  capacity,  100  to  200  amperes, 
should  be  used.^  The  current  used  for  the  patient  and  the  motor  should 
come  from  two  separate  sources.  The  current  to  be  used  for  the  patient  is 
connected  with  the  inlet  binding  posts  of  a  graphite  rheostat.  A  wire  po- 
tentiometer should  not  be  used  because  it  brings  troublesome  inductance 
into  the  circuit,  as  is  explained  in  Figures  265,  266,  267,  and  268. 
The  current  is  interrupted  on  the  negative  pole ;  this  pole  is  connected  as 
follows :  a  wire  connects  the  outlet  binding  post  of  the  potentiometer 
(negative  pole)  with  the  wheel  interrupter,  a  milliamperemeter,  a  switch, 
and  finally  a  resistance  box  (Wheatstone  bridge  or  any  graded  resist- 
ance). The  other  binding  post  of  the  potentiometer  (positive)  is  con- 
nected directly  with  the  bridge.  The  resistance  put  into  the  circuit  is 
from  300  to  500  ohms.  The  resistance  represents  the  patient  or  the  ani- 
mal. The  circuit  is  then  closed  by  means  of  the  switch.  A  voltmeter  is 
connected  in  shunt;  all  the  other  instruments  are  in  series.  The  wheel 
interrupter  is  put  in  such  a  position  as  to  allow  the  passage  of  the  direct 
current  without  interrupting  it  (the  wheel  is  not  revolving).  The  volt- 
meter indicates,  say,  40  volts;  the  milliamperemeter  indicates,  say,  20 
milliamperes.  Now  the  wheel  interrupter  is  made  to  revolve  by  means  of 
the  motor,  say,  1,500  to  2,000  times  per  minute.  Whatever  the  amper- 
age is  while  the  wheel  is  interrupting  the  direct  current,  it  is  the  aim  to 
regulate  the  period  of  the  passage  of  the  current  so  as  to  have  it  pass  only 
1/10  of  the  time,  9/10  being  lost.  This  is  accomplished  by  changing  the 
position  of  the  adjustable  contact  lever  in  relation  to  the  fixed  lever  on 
the  wheel,  while  the  latter  is  revolving.  Keep  on  adjusting  the  movable 
lever  until  the  milliamperemeter  that  registered  20  milliamperes  when 
the  wheel  was  stationary  now  registers  only  2  milliamperes  while  it  is  re- 
volving. The  period  of  the  passage  of  the  current  is  now  1/10.  It  is  of 
the  utmost  importance  in  this  work  and  should  be  regulated  every  time 

Application,  Presentation  of  Patients,"  J.  Ment.  Path.,  1909,  No.  4;  also,  "Pres- 
entation of  Instmments:  Motor-interrupter  Supplying  a  Current  of  Frequent 
Interruption  for  Electric  Anesthesia, ' '  J.  Ment.  Path.,  1909,  8,  No.  4. 

^  Robinovitch :  ' '  Electric  Anesthesia,  Its  Use  in  Laboratory  Work, ' '  J. 
Ment.  Path.,  1907,  No.  3 ;  also, ' '  Anesthesie  electrique ;  application  clinique ;  pres- 
entation de  malades  et  d 'instruments, "  B^lll.  d.  I.  Soc.  Clinique  d.  Med.  ment., 
Nov.,  1908,  No.  4;  also,  "Motor-interrupter  Supplying  a  Current  of  Frequent 
Interruption  for  Electric  Anesthesia,"  Bull.  d.  I.  Soc.  Clinique  d.  Med.  ment., 
Nov.,  1908. 


Fig.  265. — Myogram  No.  5.  Unipolar  Method.  Reaction  at  make  and  break  of  direct- 
current  feeding  field  coils.  At  break  of  current  reaction  is  more  marked  than  at  make. 
M,  make;  B,  break. 


Fig.  266. — Myogram  No.  6.  Reactions  at  make  of  direct-current  feeding  field  coils,  at 
make  of  arc  and  at  break  of  direct-current  feeding  field  coils  and  vacuum  tube.  M, 
make;  A,  arc;  B,  break. 


Fig.  267. — Myogram  No.  7.  Upper  tracing;  wireless;  one  end  of  wire  connected  with 
binding  post  of  damp  chamber.  Other  end  of  this  wire  held  at  a  distance  of  fifteen 
centimeters  from  field  coils  and  arc  in  vacuum  tube;  these  coils  and  arc  in  vacuum 
tube  in  operation.  No  weight  on  muscle.  Lower  tracing:  end  of  the  wire  three  cen- 
timeters from  tube  anode.  Reactions  take  place  at  make  and  break  of  arc  in  vacuum 
tube. 


Fig.  268. — Myogram  No.  8.  Lower  tracing:  primary  coU  only;  "wired"  circuit  with 
"gap"  of  five  centimeters.  M,  reaction  as  soon  as  ribbon  vibrator  is  in  operation  and 
magnetic  flux  brought  into  play.  T,  reaction  while  operator  was  touching  base  of 
stand  holding  muscle-nerve  preparation.  Rest  of  trace,  spontaneous  irregularity, 
while  free  end  of  wire  was  held  in  magnetic  flux.  Upper  tracing:  with  a  circuit  "gap" 
of  five  centimeters  and  end  of  wire  held  near  magnetic  fiux.  No  reaction  when  wires 
withdrawn  from  field. 


632 


ANESTHESIA 


before  an  experiment  is  commenced.^  Now  reduce  the  current  to  zero 
with  the  potentiometer,  break  the  circuit  by  opening  the  switch,  take  out 
the  bridge  and  substitute  for  it  an  animal  or  a  patient.     The  wheel  is 


Fig.  269. — Myogram  No.  9,  "Unipolar."  Primary  coil  only  (10  inches  long,  six  layers  of 
wire,  of  which  diameter  is  ^f  mm.,  condenser  in  circuit.  Core  one  inch  in  diameter. 
No  weight  on  muscle) ;  reaction  when  one  end  of  the  single  wire  is  connected  with 
damp  chamber,  the  other  end  touching  any  part  of  the  metal  frame  near  magnetic  flux. 
M,  reaction  when  end  of  wire  touches  any  part  of  metal  frame;  T,  operator  touch- 
ing with  hand  base  of  drum  on  which  trace  is  registered;  S,  operator  touching  base 
of  stand  holding  muscle-nerve  preparation. 


made  so  that  it  can  interrupt  the  current  from  6,000  to  12,000  times  per 
minute,  according  to  the  speed  of  its  rotation. 

It  is  dangerous  to  use  any  other  current  than  that  indicated  above. 
Alternating,  induction,  rectified  currents,  or  those  supplied  by  ordinary 


Fig.  270. — Myogram  No.  10.  "Wireless."  No  weight  on  muscle.  From  below  upward ; 
lowest  line;  Tesla  high  frequency.  Preparation  grounded;  no  spark  across  Tesla  ter- 
minal apparatus  one  foot  away  from  preparation.  The  two  upper  traces:  oscilla- 
tions conducted  to  preparation  by  operators'  body,  as  explained  in  the  text.  Spark 
across  Tesla  terminals. 


wet  batteries  are  dangerous  for  this  work.  Irregular  direct  currents  are 
equally  dangerous.  Bad  results  may  be  obtained  in  experiments  in  ani- 
mal surgery  by  irregular  currents,  when  laundries  and  elevators  are  run 
by  power  taken  from  the  same  main  line  as  that  supplying  the  labora- 
tories. Unsuitable  apparatus  combined  with  such  markedly  uneven  cur- 
rents accounts  for  death  and  convulsions  in  animals,  especially  when  too 

^  A  firm  in   New   York  has  constructed,   under   our   direction,   an   interrupter 
with  a  fixed  period  of  the  passage  of  the  current. 


ELECTRIC   ANALGESIA,   SLEEP,   AND   RESUSCITATION     633 

hio-h  amperage  is  used.  Correct  technical  construction  of  the  apparatus  is 
of  utmost  importance. 

When  used  with  a  wire  potentiometer  in  the  circuit,  even  our  best 
model  of  interrupter  caused  muscular  rigidity  because  of  inductance.  The 
myograms  fully  explain  the  difficulty. 

We  have  found  that  sul)stitution  of  a  graphite  rheostat  for  one  made 
of  wire  eliminates  this  difficulty  to  a  large  extent. 

Application  in  Man, — For  Inducing  Sleep. — Leduc  was  the  first  to 
submit  himself  to  electric  "sleep."     Eouxeau  and  Malherbc  applied  the 


Fig.  271. — Myogram  No.  11.  "Wireless."  Weight  on  muscle.  From  above  down- 
ward: 1,  reaction  at  a  distance  of  2  meters;  each  end  of  solenoid  screwed  into  respective 
binding  posts  on  disc  of  damp  chamber;  2,  reaction  at  a  distance  of  2  meters,  one  end 
of  solenoid  being  free  in  the  air;  3,  reaction  at  a  distance  of  23^^  meters,  solenoid  with 
one  free  end  in  the  air  reinforced. 

current;  the  experiment  was  not  pushed  far  enough  to  produce  complete 
anesthesia;  35  volts  and  4  milliamperes  were  used  centrally. 

In  our  work  we  distinguish  between  electric  sleep  and  analgesia.  We 
produce  electric  sleep  in  patients  suffering  from  insomnia  by  applying 
to  the  forehead,  the  negative  electrode  shaped  to  the  forehead  and  the  posi- 
tive electrode  to  the  palm  of  the  right  hand.  The  current  is  turned  on 
slowly,  generally,  some  5  minutes  being  consumed  in  turning  on  %  of  a 
milliampere.  When  this  amount  of  current  is  reached,  the  patient  feels 
a  tingling  sensation  through  his  head  and  falls  asleep  within  a  few 
minutes.  A  small  flag  mounted  on  a  little  block  of  wood  is  placed  upon 
the  patient's  chest ;  the  flag  moves  with  the  movements  of  the  chest,  that 
are  watched  all  the  time  while  tlie  patient  is  slee]3ing.  We  generally  allow 
the  current  to  course  through  the  body  for  1  hour,  then  turn  it  off;  but 
the  patient  continues  to  sleep.  On  awakening  the  patient  feels  re- 
freshed ;  if  he  is  very  sensitive,  he  may  remark  that  he  feels  "a  bit  chilly." 
This  chilly  feeling  is  probably  caused  by  the  vasoconstriction  during  the 
passage  of  the  current. 


634  ANESTHESIA 

For  Local  Purposes. — In  clinical  work  we  have  applied  electric  anes- 
thesia in  numerous  cases.  The  chosen  part  of  the  body  or  limb  is  in- 
cluded in  the  circuit,  the  cathode  always  being  nearer  the  central  nerv- 
ous system,  the  anode  being  the  distal  electrode.  If  the  chest  is  in  the 
circuit  the  amperage  should  be  governed  judiciously. 

For  Surgical  Purposes. — We  applied  local  electric  analgesia  in 
man  for  surgical  purposes  in  1910;  the  patient,  a  man  twenty-three 
years  old,  was  at  the  St.  Francis  Hospital,  Hartford,  Conn.  M.  M. 
Johnson,  assisted  by  Edward  Herr,  operated.  The  patient  talked  with 
those  near  him  while  his  toes  were  being  amputated.  The  great  toe  of 
one  foot  and  the  great,  second  and  third  toes  of  the  other  were  ampu- 
tated. The  operation  was  "bloodless."  Four  milliamperes  of  current 
and  54  volts  were  used  in  this  case.  Other  surgical  cases  in  which  we 
applied  electric  analgesia  locally  are  not  yet  published.  One  of  these 
was  a  major  operation  of  the  lower  limb  and  was  also  "bloodless."  The 
vasoconstriction  accounts  for  the  insignificant  loss  of  blood. 

In  some  cases  we  used  9  milliamperes  for  amputation  of  the  toes 
(one  in  a  man,  another  in  a  woman)  and  18  milliamperes  for  resection 
of  the  leg  in  a  man.  Neither  one  of  these  patients  withdrew  the  limbs 
during  the  operation,  although  the  surgeons  urged  them  to  do  so  if  they 
felt  pain.  They  only  complained  of  the  tingling  sensation  caused  by 
these  strong  currents.  We  believe,  therefore,  that  4  milliamperes  of 
current,  applied  with  electrodes  of  the  dimensions  reported  by  Johnson, 
are  most  favorable. 

Local  analgesia  depends  entirely  on  proper  technique  in  the  applica- 
tion of  the  electrodes.  In  the  lower  extremities  application  of  the  elec- 
trodes is  quite  easy,  because  the  anterior  crural  nerve  and  its  accompany- 
ing vessels  in  Scarpa's  triangle  are  readily  reached  with  an  electrode; 
so  are  the  anterior  and  posterior  tibial  nerves  in  the  leg.  In  the  upper 
extremities  it  is  rather  difficult  to  hold  the  electrode  applied  over  the 
large  trunks  of  nerves  and  vessels.  When  the  electrodes  are  properly 
applied  to  them  the  analgesia  is  good ;  but  it  is  difficult  to  keep  the  elec- 
trodes in  their  proper  places. 

Locally,  the  amperage  may  readily  be  increased  above  4  milliam- 
peres; we  do  not  recommend  higher  amperage  than  4  milliamperes  of 
the  interrupted  current;  but  5  or  6  milliamperes  may  sometimes  be 
necessary.  Centrally,  4  milliamperes  is  as  strong  a  current  as  should 
be  applied.  Currents  slightly  stronger  than  this  should  be  used  by  none 
but  the  expert  in  this  work.  The  major  advantage  of  this  analgesia  is 
that  it  is  not  dangerous  when  properly  applied,  with  proper  instruments 
and  proper  currents.^ 

^  This  is  part  of  a  paper,  ' '  Electric  Anesthesia  and  Electric  Eesuscitation 
After  Heart  Failure  under  Chloroform  or  Electrocution. ' '    Eead  in  the  Section  of 


ELECTRIC   ANALGESIA,   SLEEP,   AND   RESUSCITATION     635 

Contraindications. — Electric  sleep,  and  particularly  analgesia, 
when  applied  centrally,  causes  abortion  in  pregnant  animals.  The  cur- 
rent is  contraindicated  in  cases  of  high  arterial  pressure,  in  the 
apoplectic  and  in  the  epileptic,  because  this  current  increases  arterial 
tension. 

Electric  sleep  or  analgesia  should  not  be  combined  with  morphini- 
zation,  chloroforming,  or  soporific  agents.^ 

Electric  Analgesia  and  Sleep  in  Wireless  Circuits.^ — In  1909  a  new 
variety  of  electric  current  was  used — one  produced  by  a  Vreeland  oscil- 
lator.* Babbits  and  dogs  were  subjected  to  the  effects  of  this  current  and 
a  certain  degree  of  analgesia  and  sleep  was  produced.  In  one  rabbit  the 
tissues  of  the  back  of  the  chest  were  even  cut  through  and  the  bones  of 
the  spinal  column  scraped  with  a  knife,  without  causing  any  apparent 
reaction  to  pain.  But  in  dogs  we  could  not  produce  any  analgesia  for 
operative  purposes  without  using  a  current  so  strong  that  it  caused 
excessive  muscular  rigidity  and  endangered  life.  The  more  interesting 
feature  of  the  effects  of  this  pulsating  current  was  in  regard  to  sleep. 
A  dog  was  put  into  a  closed  wired  circuit  of  this  current.  The  animal 
remained  stretched  out  on  its  side,  in  a  condition  of  muscular  relaxation, 
during  a  period  of  3  hours,  when  one  of  the  electrodes  accidentally  be- 
came disconnected.  The  animal,  however,  continued  in  a  condition  of 
somnolence  for  14  hour  thereafter,  despite  the  continued  disconnection 
of  one  electrode  in  this  circuit.  A  pin  was  thrust  through  its  skin  and 
the  animal  arose  to  its  feet.  We  repeated  similar  experiments  of  uni- 
polar connection  with  the  working  current  of  the  oscillator,  and  similar 
results  were  obtained.  We  then  disconnected  both  electrodes,  and  still 
the  dog  remained  on  its  side  in  a  drowsy  condition  upon  the  table, 
awaking  only  when  shaken  vigorously. 

While  the  animal  remained  in  a  drowsy  condition  the  oscillator  was 
in  operation.  The  oscillator's  important  features  in  relation  to  this 
sleep  were  not  the  working  current  supplied  by  the  apparatus,  this  cur- 
rent not  being  used  then,  but  the  two  field  coils  and  rapid  electric  oscil- 
lations in  the  vacuum  tube  of  the  apparatus  made  for  the  purpose  of 
supplying  the  working  current.     The  magnetic  flux  and  the  arc  in  the 

Pathology  and  Physiology  of  the  American  Medical  Association,  St.  Louis,  Mo., 
June,  1910. 

^Robinovitch:  "Electric  Anesthesia  in  Laboratory  Surgery  Successfully  Ap- 
plied During  a  Period  of  Three  Years.  Demonstration  on  an  Animal  and  Clinical 
Application,  Presentation  of  Patients,"  J.  Ment.  Path.,  1909,  No.  4;  also,  "Pres- 
entation of  Instruments:  Motor-interrupter  Supplying  a  Current  of  Frequent 
Interruption  for  Electric  Anesthesia,"  J.  Ment.  Path.,  1909,  8,  No.  4. 

^Med.  Bee,  Dec,  1910. 

* Robinovitch :  "Physiological  Effects  of  a  New  Variety  of  Electric  Cur- 
rent," J.  Ment.  Path.,  1909,  8,  No.  4;  Med.  Bee,  Dec.  11,  1909,  1009. 


636  ANESTHESIA 

vacuum  tube  caused  displacement  currents  in  the  air,  as  is  shown  in  the 
myogram  studies. 

In  our  experiments  the  continuance  of  electric  sleep  in  dogs  by- 
means  of  displacement  currents  was  practised  after  the  animals  had  been 
subjected  to  the  effects  of  the  pulsating  current  conducted  through  a 
closed  wired  circuit  during  periods  of  from  2  to  3  hours.  We  are  not  in 
a  position  to  affirm  that  this  sleep  could  be  obtained  in  all  dogs  without 
the  preliminary  effect  of  the  pulsating  current  in  a  wired  circuit.  But 
myograms  obtained  demonstrate  the  decided  effect  of  displacement  cur- 
rents on  living  tissues;  these  studies  seem  to  indicate  that,  where  we 
failed  to  produce  sleep  with  displacement  currents  at  our  disposal,  it  was 
because  these  currents  were  not  sufficiently  strong  for  the  purpose. 

In  these  experiments  the  muscle-nerve  preparation  is  in  a  damp 
chamber,  covered  with  a  glass  globe;  the  nerve  lies  across  two  non- 
polarizable  electrodes ;  these  electrodes  are  filled  with  a  saturated  solution 
of  zinc  sulphate,  and  wires  connect  them  with  binding  posts  on  the  disk 
of  the  damp  chamber. 

Conclusions. — Living  beings  and  muscle-nerve  preparations  react  to 
displacement  currents.  A  muscle-nerve  preparation  may  react  to  cur- 
rents that  an  ordinary  telephone  receiver  does  not  detect.  A  muscle- 
nerve  preparation  seems  to  be  a  sensitive  detector  of  displacement  cur- 
rents. 

An  electromagnetic  flux  of  an  ordinary  portable  small-sized  primary 
coil  with  a  ribbon  vibrator  in  operation  causes  muscle-nerve  reaction  in 
circuits  with  gaps  of  from  3  to  5  centimeters.  A  larger  electromagnetic 
flux  (core  10  inches  long,  1  inch  in  diameter,  primary  coil  six  layers 
of  wire,  diameter  12/10  mm.,  with  condenser  on  primary)  causes  marked 
reaction  by  unipolar  methods.  It  is  possible  to  produce  effects  on  ani- 
mal and  living  tissue  by  means  of  unipolar  and  wireless  methods.  The 
question  of  producing  sleep  in  man  in  paths  of  displacement  currents 
requires  further  study. 

In  our  studies  of  wireless  effects  of  displacement  currents  on  living 
tissue,  positive  results  have  also  been  obtained  without  grounding  the 
muscle-nerve  preparations  and  even  when  everything  connected  with 
the  experiment  was  insulated  on  a  platform.  This  proved  that 
reactions  could  be  obtained  by  reason  of  free  displacement  currents  in 
the  air.^ 

Electric  Analgesia,  and  Electric  Resuscitation  after  Heart  Failure 
"Under  Chloroform  or  Electrocution.^ — By  the  use  of  electric  currents  it 
is  possible  to  resuscitate  subjects  in  a  condition  of  apparent  death  caused 

^Med.  Bee.,  Aug.  13,  1910. 

=  "  Electric  Anesthesia  and  Electric  Eesuscitation  After  Heart  Failure  under 
Chloroform  or  Electrocution."  Am.  Med.  Assn.,  June,  1910.  The  part  on  resus- 
citation was  published  in  the  J.  Am.  Med.  Assn.,  Feb,  18,  1911,  56,  478-481. 


ELECTRIC   ANALGESIA.   SLEEP,   AND   RESUSCITATION    637 

by  chloroform,  ether,  morphin,  electrocution,  etc.  The  first  important 
researches  into  resuscitation  of  electrocuted  subjects  were  made  at  about 
the  same  time  by  Battelli  ^  in  Europe  and  H.  H.  Cunningham  in  this 
country.^  Both  authors  used  enormous  currents  for  causing  single  elec- 
tric shocks  with  which  they  attempted  to  restore  life  after  ventricular 
tremulation  had  set  in.  Battelli  used  4,800  and  2,400  volts  respectively, 
of  alternating  currents  (amperage  not  stated).  The  means  was  not 
practical  because  one  shock  caused  with  such  high  voltage  was  all  the 
heart  could  stand;  a  second  shock  killed  the  animal  definitely. 

Leduc  and  Eouxeau  ^  tried  to  resuscitate  animals  by  means  of  direct 
interrupted  currents  of  low  tension,  but  they  committed  their  prede- 
cessors' error  of  including  the  animal's  head  in  the  circuit.  Besides,  they 
used  the  lethal  current  for  producing  the  shocks.  The  method  was  use- 
less in  cases  of  dogs. 

Exclusion  of  the  Head. — While  experimenting  on  the  cerebral  circu- 
lation during  electric  epilepsy,*  we  saw,  through  a  trephined  opening  in 
the  skull,  that  every  electric  shock  caused  profound  anemia  of  the  brain 
at  the  time  of  the  closure  of  the  circuit.  This  led  us  to  exclude  the  ani- 
mal's head  from  the  circuit  during  the  rhythmic  excitations,  in  order 
to  exclude  the  medulla  oblongata  with  the  cardiac  and  respiratory  cen- 
ters, and  to  avoid  any  further  anemia  of  these  centers  during  apparent 
death,  while  the  electric  rhythmic  excitations  were  being  practiced.  We 
also  reduced  the  current  to  minimal  doses  for  the  first  rhythmic  excita- 
tions, because  we  found  that  useful  cardiac  and  respiratory  excitability 
was  rapidly  exhausted  within  the  few  minutes  of  apparent  death.  The 
maximum  potential  at  the  end  of  the  resuscitation  did  not  exceed  120 
volts.  Even  this  is  too  high  voltage:  in  dogs  it  causes  marked  vagus 
stimulation,  so  that  the  heart  beats  are  very  slow  during  a  long  period 
of  time  after  resuscitation,  and  the  wave  form  of  the  beat  does  not  re- 
semble the  normal  form.  In  ordinarily  severe  cases,  70  volts  is  a  good 
maximum  potential.^ 

^  Battelli  and  Prevost:  "La  mort  par  les  courants  electriques:  courant 
alternatif  a  bas  voltage  et  a  haute  tension,  "J.  d.  Physiol,  et  de  Path,  gen.,  May, 
1899. 

-Cunningham:  "The  Cause  of  Death  from  Industrial  Electric  Currents," 
N.  Y.  Med.  J.,  1899,  70. 

^Quoted  by  Eobinovitch,  in  "Sommeil  electrique,  epilepsia  electrique  et 
electrocution,"  These,  Paris,  1906. 

*  Eobinovitch :  "General  and  Cerebral  Blood  Pressure  During  an  Attack  of 
Electric  Epilepsy,"  J.  Ment.  Pathol,  1907,  8,  No.  3. 

°  Eobinovitch :  ' '  Method  of  Eesuscitating  Animals  in  a  Condition  of  Cardiac 
and  Eespiratory  Syncope  Caused  by  Chloroform,"  J.  Merit.  Path.,  1907,  8,  No.  3. 
"Method  of  Eesuscitating  Electrocuted  Animals,"  ibid.;  "Method  de  rappeller 
a  la  vie  des  animaux  en  syncope  cUorofomiique  et  des  animaux  en  mort  ap- 
parente  causee  par  1 'electrocution.  Effets  differents  de  differents  courants  elec- 
triques.   Importance    d 'exclusion    du    circuit    electrique    de    la    tete    de    1 'animal 


638  ANESTHESIA 

The  method  of  resuscitation  consists  in  causing  artificial  blood  pres- 
sure and  respirations  by  means  of  rhythmic  electric  excitations,  until 
normal  function  is  restored. 

Kind  of  Current  Used. — Our  choice  of  electric  current  is  the  one  we 
use  for  causing  electric  sleep  and  analgesia :  a  direct  current,  interrupted 
from  6,000  to  8,000  times  per  minute,  period  1/10.  Next  in  value  is  a 
direct  current  interrupted  from  25,000  to  40,000  times  per  minute  with 
a  triple  interrupter.^  The  last  choice,  and  the  one  that  we  do  not  rec- 
ommend if  the  first  two  can  be  had,  is  an  induction  current  obtained  with 
our  special  model  of  induction  coil,  an  ordinary  Dubois-Reymond  coil, 
the  special  feature  of  which  is  the  diameter  of  the  wire  of  the  coil,  1.2 
mm.  for  the  primary  and  0.6  mm.  for  the  secondary  coil.^  In  cases  of 
grafve  forms  of  apparent  death,  currents  supplied  by  coils  with  fine  wire 
will  kill  the  animal.^  Induction  currents  are  alternating  currents,  the 
wave  form  of  the  current  running  above  and  below  the  base  line.  The 
physiologic  effects  of  anodal  and  cathodal  stimulations  are  distinctly  dif- 
ferent; the  anodal  stimulations  are  particularly  dangerous  in  pulmonary 
and  cardiac  areas  when  the  current  is  obtained  from  a  secondary  coil  the 
wire  of  which  is  finer  than  0.6  mm.  Alternating  and  direct  currents  are 
deadly  to  cellular  life,  especially  during  apparent  death.*  But,  if  noth- 
ing else  can  be  had,  rhythmic  excitations  may  be  practiced  with  these 
currents,  rather  than  make  no  attempt  to  save  life. 

Procedure. — The  dog's  back  is  shaved  in  two  places — on  the  chest 
covering  the  pulmonary  area  and  the  back  over  the  loins.  The  negative 
electrode  is  applied  under  the  chest,  the  upper  border  reaching  to  the 
root  of  the  neck.  It  is  dangerous  to  use  the  positive  pole  under  the  chest. 
The  positive  electrode  is  applied  over  the  loins.  The  electrodes  measure 
12  by  25  cm.  for  dogs  of  large  size.  They  are  made  of  zinc  and  are  cov- 
ered with  a  thick  layer  of  absorbent  cotton  wet  in  a  salt  solution,  7 :  1000. 
In  man  the  chest  electrode  measures  25  by  30  cm. 

Chloroforming  is  performed  intensively,  admitting  little  or  no  air 

pendant  les  excitations  rythmiques, "  Compt.  rend.  Soc.  de  Biol.,  Feb.  1,  1908; 
"De  I'emploi  des  courants  electriques  pour  le  rappel  a  la  vie,  dans  les  cas  de 
mort  apparente  causee  par  le  chloroforme  ou  par  1 'electrocution.  Necessite 
d  'exclure  du  circuit  la  tete,  pendant  les  excitations  rythmiques.  Experiences 
pratiquees  sur  le  chien.  Application  clinique, ' '  Bull.  Soc.  Clin,  de  Med.  ment., 
Nov.,  1908;  "Resuscitation  of  Subjects  in  a  Condition  of  Apparent  Death,"  etc., 
J.  Ment.  Path.,  1909,  8,  No.  4. 

* Robinovitch :  "Triple  Interrupter  of  Direct  Currents  for  Resuscitation. 
Portable  Model  for  Ambulance  Service, ' '  J.  Ment.  Path.,  1909,  8,  No.  4. 

^  Robinovitch :  ' '  Bobine  a  induction  pour  rappel  a  la  vie,  etc., ' '  Bull.  Soc. 
Clin.  d.  Med.  ment.,  Nov.,  1908 ;  ' '  Induction  Coil  for  Purposes  of  Resuscitation, ' ' 
J.  Ment.  Path.,  1909,  8,  No.  4. 

*  Robinovitch :     Thesis,  loc.  cit. 

*  Robinovitch :  "Different  Effects  of  Various  Electric  Currents  for  Pur- 
poses of  Resuscitation,  etc. ' '  J.  Ment.  Path.,  1909,  8,  No.  4. 


ELECTRIC   ANALGESIA,   SLEEP,   AND   RESUSCITATION    639 

and  causing  arrest  of  respiration  and  heart  beats  as  quickly  as  possible. 
When  breathing  is  no  longer  registered  by  the  pneumograph  and  the 
manometer  does  not  register  any  blood  pressure,  the  chloroforming  is 
discontinued  at  once.  An  assistant  holds  the  animal's  tongue  with  a 
tongue  forceps,  cleanses  the  mouth  of  mucus,  and  pulls  the  tongue  out- 
ward to  allow  free  access  of  air  during  the  rhythmic  excitations. 

The  instrumentation  with  the  preferred  current  is  the  same  as  that 
used  for  electric  sleep.  The  operator  now  opens  the  switch  of  the 
cathode  line  and  turns  on  a  current  of  some  20  to  25  volts  by  means  of 
the  potentiometer.  The  circuit  is  then  closed  by  means  of  the  switch  for 
a  fraction  of  a  second.  A  deep  inspiratory  movement  takes  place.  The 
mouth  opens,  the  flabby,  lifeless  tongue  that  was  lying  on  the  roof  of 
the  mouth  (the  animal  is  on  its  back)  contracts  and  is  drawn  inward; 
the  fore  paws  are  thrust  upward  with  marked  force;  the  posterior  limbs 
are  extended;  the  diaphragm  is  pushed  downward  and  all  the  respira- 
tory muscles  enter  into  play.  The  chest  is  fully  expanded  and  the  pneu- 
mograph registers  an  ample  artificial  inspiration.  The  manometer 
may  also  register  an  artificial  blood  pressure;  but  in  cases  of  severe  car- 
diac syncope  the  first  few  rhythmic  excitations  cause  respiratory  reaction 
without  artificial  blood  pressure.  The  operator  breaks  the  circuit  by 
opening  the  switch.  This  is  followed  by  a  deep  expiratory  movement,  and 
all  the  muscles  that  entered  into  play  to  cause  the  artificial  inspiration 
are  now  again  fiabby  and  lifeless;  the  expanded  chest  collapses  and  the 
pneumograph  registers  an  ample  expiration;  the  anterior  paws  fall  one 
on  each  side  of  the  body,  the  tongue  falls  to  the  roof  of  the  mouth,  life- 
less, the  mouth  closes  and  the  whole  body  is  again  lifeless  and  relaxed. 
The  switch  is  kept  open  for  a  period  of  from  %  to  1  second,  according 
to  the  gravity  of  the  case.  If  the  first  voltage  used  causes  an  ample 
respiratory  reaction  and  the  manometer  shows  a  momentary  rise  of 
blood  pressure,  the  succeeding  rhythmic  excitation  is  caused  with  the 
same  voltage,  but,  as  a  general  rule,  it  is  necessary  to  increase  the  cur- 
rent to  30  volts  or  more;  the  excitations  are  now  practiced  with  the  in- 
creased current,  the  aim  being  to  obtain  ample  respiratory  reaction  and 
blood  pressure  with  this  minimal  voltage  within  the  shortest  possible 
time,  because  useful  cardiac  excitability  is  quickly  exhausted  during 
apparent  death.  It  is  generally  necessary  to  increase  the  current  to  35, 
40,  50,  60,  and  70  volts  within  the  course  of  3  or  more  minutes  of  ap- 
parent death;  the  excitations  are  being  practiced  while  the  voltage  is 
being  increased.  In  favorable  cases  ample  respiratory  reaction  and  ar- 
tificial blood  pressure  are  soon  established,  then  accompanied  by  feeble 
spontaneous  respiratory  and  cardiac  reactions;  these  soon  increase  in 
amplitude;  they  are  alternated  with  ample  artificial  reactions  if  neces- 
sary, taking  care  not  to  encroach  on  the  spontaneous  heart  beats  and 
respirations,  but  rather  to  precede  or  to  follow  them.     The  operator 


Fig.  272. — Tracing  No.  1.  Made  During  Usual  Form  op  Apparent  Death  Caused 
BY  Intensive  Chloroforming  in  a  Dog.  Upper  tracing,  respiration;  second  tracing, 
blood-pressure  in  carotid  artery;  third  tracing,  time;  two  lines  indicate  one  second, 
during  cardiac  failure  only.  In  rest  of  tracing:  one  line  indicates  one  second.  R, 
respiratory  syncope;  C,  cardiac  syncope;  E,  commencement  of  electric  rhythmic  excita- 
tions (direct  current  interrupted  8,000  times  per  minute,  period  1-10) ;  gradual  in- 
creasing current  from  20  to  65  volts.  The  ample  respiratory  and  cardiac  reactions  are 
artificial,  caused  by  the  rhythmic  excitations;  then  the  small  spontaneous  heart-beats 
appear  and  alternate  with  the  ample  artificial  ones.  The  cross  shows  where  the  first 
small  spontaneous  respiration  appeared ;  ample  artificial  respirations  alternate  with  the 
small  spontaneous  ones.  S,  synchronous  respirations  and  heart-beats;  final  resuscita- 
tion. 


1     0/i 

,^^ ^^^,^T-,^.'-rt^,-,.^rf-,Ttvn>'^rtU^i+*»iJli-'*^-. — 1-^ — 

'y^'^\. ' 



X, 

/\m'mt^""- 

B^BB 

Fig.  273. — Tracing  No.  2.  Primary  Cardiac  Syncope  in  Dog.  Intensive  chloroform- 
ing. Upper  line,  respiration;  second  line,  blood  pressure  in  carotid  artery;  third  line, 
signal;  fourth  line,  time,  one  second.  Tracing  reduced  one-half.  Imitation  of  method 
used  by  surgeons  (Sylvester  method) :  small  respiratory  reaction  caused  by  limited 
current  of  8  volts  (6,000  interruptions  per  minute,  period  1-10).  S,  cardiac  syncope, 
respirations  continuing;  R,  rhythmic  excitations;  C,  commencement  of  spontaneous 
cardiac  beats;  D,  spontaneous  respiration  does  not  appear;  commencement  of  descent 
of  blood  pressure,  ending  in  death  of  animal. 


ELECTRIC   ANALGESIA,   SLEEP,   AND   RESUSCITATION    641 

Judges  by  the  spontaneous  cardiac  and  respiratory  reactions  when  it  is  ad- 
visable to  discontinue  the  rhythmic  excitations.  If  they  are  discontinued 
too  soon,  death  may  set  in  -after  resuscitation,  because  iji  chloroform  poi- 
soning the  blood  is  asphyxiated  and  dark;  the  feeble  respirations  and 
heart  beats  may  not  be  sufficient  to  cause  useful  oxygenation  of  tlie  blood. 
But  once  ample  spontaneous  reactions  are  established,  the  carotid  artery 
is  tied,  the  wound  is  closed,  and  the  animal  lives  without  showing  any 
ill  effects.  We  have  kept  such  dogs  during  a  period  of  one  year  and 
longer  after  resuscitation;  they  were  in  excellent  condition. 


:U)iiliii(:i| 


v^^.**Jir'w,wM*i^*iitMv.-'Wi.^^^^^^ 


Fig.  274. — Tracing  No.  3.  Primary  Cardiac  Syncope  in  Dog.  Intensive  chloroforming. 
Upper  line,  respiration;  second  line,  blood  pressure  in  carotid  artery;  third  line,  signal; 
fourth  line,  time,  one  second.  Tracing  reduced  one-half.  S,  cardiac  syncope,  respira- 
tion continuing ;  E,  commencement  of  the  rhythmic  excitations  with  induction  current, 
wire  of  secondary  coil  6-10  mm.  in  diameter;  gradually  increasing  current  causes 
gradually  increasing  amplitude  of  artificial  respirations;  C,  commencement  of  ample 
artificial  heart  beats;  small  heart  beats  are  spontaneous  and  alternate  with  artificial 
ones;  R,  spontaneous  respirations  and  final  recovery. 


Limitations.^ — The  period  of  apparent  death  is  short;  four  minutes 
(including  the  time  of  the  rhythmic  excitations)  is  a  long  time,  and  5 
minutes  is  an  exceedingly  long  period.  But,  once  resuscitated,  the  ani- 
mal lives  and  shows  no  after-effects. 

In  chloroform  poisoning  death  may  take  place  in  various  ways :  By 
respiratory  arrest  and  ensuing  cardiac  failure,  which  is  the  usual  form 
in  man;  by  primary  cardiac  failure,  which  is  a  rare  form  in  dogs,  but 
is  quite  familiar  to  surgeons  in  the  case  of  human  beings ;  and  by  simul- 
taneous cardiac  and  respiratory  arrest.  In  the  majority  of  cases,  in 
human  beings  as  well  as  in  dogs,  death  sets  in  by  respiratory  paralysis 
followed  by  cardiac  failure. 

Figure  272  shows  the  usual  form  of  apparent  death  from  chloro- 
form poisoning  and  the  mode  of  resuscitation  by  electric  rhythmic  ex- 
citations with  a  gradually  increasing  current.  The  amperage  cannot  be 
read  in  these  experiments  because  the  closures  are  of  too  short  duration, 
but  there  are  generally  between  4  and  40  milliamperes  of  current  used. 


642  ANESTHESIA 

This  amperage  was  obtained  in  experiments  on  dogs  sacrificed  for  this 
purpose. 

Figure  273  shows  primary  cardiac  syncope  in  a  dog  during  chloro- 
forming; imitation  of  the  Sylvester  method  of  resuscitation:  feeble 
current  causing  the  delayed  and  feeble  cardiac  and  respiratory  reaction 
that  ends  in  death. 

Figure  374  shows  primary  cardiac  syncope  in  a  dog  during  chloro- 
forming; resuscitation  was  practiced  by  gradually  increasing  the  cur- 
rent. The  result  was  recovery.  Electrocuted  dogs  are  resuscitated  less 
easily  than  are  chloroformed  dogs.  It  is  especially  difficult  to  resuscitate 
when  ventricular  tremulation  sets  in. 

All  experimenters  on  this  subject  agree  that  artificial  respiration 
and  the  Sylvester  method  are  useless  when  ventricular  tremulation  sets 
in.^  Our  method  seems  to  give  the  best  results  known  to-day  for  prac- 
tical application,  because  it  produces  ample  artificial  blood  pressure  as 
well  as  respiration. 

Application  in  Accidental  Electrocution. — According  to  personal 
information  given  us  by  practical  electricians  both  in  Europe  and  this 
country,  death  does  not  always  take  place  instantaneously  in  accidental 
electrocution  with  moderate  industrial  currents.  The  workingman  gen- 
erally touches  the  "live"  wire  with  his  hand  or  foot ;  contact  is  generally 
"bad/'  but  it  is  sufficient  to  cause  cardiac  and  respiratory  paresis,  from 
which  the  patient  may  die  within  from  a  few  minutes  to  one-half  hour 
after  the  accident.  These  are  facts  observed  in  daily  accidents,  regard- 
less of  some  experimenters'  claim  that  all  is  well  if  the  patient's  heart 
beats  and  he  breathes  when  taken  out  of  the  circuit. 

The  blood  is  asphyxiated  and  dark,  after  the  slightest  shock;  a  few 
rhythmic  electric  excitations  will  help  to  whip  up  the  circulation  and 
respiration,  if  the  excitations  are  practiced  immediately  following  the 
accident  or  as  soon  as  possible — before  the  patient  is  removed  to  a  hos- 
pital. Without  this  help,  the  patient  may  die  when  he  is  brought  into 
the  ward — some  half  hour  after  the  accident.  The  blood  remains  as- 
phyxiated even  after  resuscitation.  This  asphyxia  may  continue  during 
many  hours. 

Application  in  Surgery. — Direct  and  indirect  cardiac  massage  has 
claimed  its  victims  of  chloroform  poisoning  in  surgical  work.^  Crile's 
method  of  resuscitation  is  admirable  as  regards  the  range  of  time  dur- 
ing which  the  heart's  action  may  be  restored.  Unfortunately,  it  pre- 
sents physiologic  limitations ;  attempted  resuscitation  after  a  period  of  7 
minutes  (in  man),  counting  from  the  time  of  cardiac  arrest,  becomes 

*  Eodenwaldfc,  Ernest :  ' '  Ueber  Verletzungen  durch  elektrische  Starkstroeme 
vomgerichtsaerzlichen  Standpunkte, "  Vrtljschr.  f.  gericht.  Med.  (3),  37,  1. 

-  White,  Charles  S. :  "  The  Kole  of  Heart  Massage  in  Surgery, ' '  J.  Surg. 
Gynec.  and  Obstet.,  Oct.,  1909. 


ELECTRIC   ANALGESIA,   SLEEP,   AND   RESUSCITATION     643 

useless,  because  the  anemia  of  the  brain  during  this  time  is  fatal  to  the 
life  of  the  brain  cells;  the  restoring  of  heart  action  becomes  useless  from 
the  point  of  view  of  restoration  of  life. 

The  method  has  the  great  advantage  of  simpli(;ity ;  it  does  not  neces- 
sitate opening  the  carotid  artery  and  injecting  a  pint  or  so  of  solutions 
into  the  heart ;  it  does  not  necessitate  opening  the  trachea.  The  method 
may  be  applied  immediately  when  the  first  sign  of  cardiac  or  respiratory 
failure  appears.  Before  an  operation  is  commenced  the  electrodes  may 
be  put  in  their  proper  places  under  the  patient;  the  chest  electrode,  25  by 
30  cm.,  the  loin  electrode,  12  by  25  cm.  The  apparatus  and  chosen  elec- 
tric source  should  be  in  readiness  before  the  operation  is  commenced. 

The  tracing  shows  that  it  is  possible  to  resuscitate  dogs  after  respira- 
tory and  cardiac  functions  are  no  longer  registered  during  a  given  period 
of  time.  It  should  not  be  assumed,  however,  that  resuscitation  is  easy  in 
all  grave  cases.  There  are  no  two  subjects  alike  in  physical  vitality.  For 
practical  application  in  surgery  the  safest  method  is  to  commence  rhyth- 
mic electric  excitations  at  the  first  sign  of  respiratory  or  cardiac  failure. 
The  surgeon  does  not  wait  until  both  the  respiration  and  the  heart  have 
failed.  In  a  series  of  experiments  on  dogs  we  commenced  the  rhythmic 
excitations  a  few  seconds  after  respiratory  syncope  set  in — in  imitation  of 
what  a  surgeon  would  do  if  he  had  a  patient  showing  signs  of  syncope 
caused  by  chloroform  or  ether.  Resuscitation  was  easy  and  complete  in 
these  experiments  after  a  few  rhythmic  excitations.  Eesuscitation  is 
more  difficult,  of  course,  when  heart  failure  dominates  in  the  accident. 

Considered  in  its  proper  light,  the  method  should  really  serve  as  a 
preventive  measure  against  grave  forms  of  syncope,  because  a  few  rhyth- 
mic excitations,  practiced  in  time,  promptly  oxygenate  the  blood  by 
reason  of  the  ample  respiratory  and  cardiac  reactions. 

Clinical  Application. — In  November,  1908,  we  had  occasion  to  revive 
a  patient  in  a  condition  of  profound  syncope  caused  by  chronic  morphin 
poisoning.  She  was  in  Magnan's  service,  Ste.  Anne  Asylum,  Paris. 
Magnan  had  revived  her  after  she  had  had  a  first  attack  of  syncope.  A 
second  attack  set  in  within  a  few  minutes;  his  assistants  attempted  to 
revive  her  by  applying  the  Sylvester  method  and  rhythmic  traction  of 
the  tongue;  this  proved  useless  during  a  period  of  20  minutes.  The  pa- 
tient's face  became  "blue"  from  asphyxia.  As  is  known,  in  morphin 
poisoning  the  respiratory  center  is  paralyzed  first,  and  heart  failure  fol- 
lows, as  is  the  case  in  ordinary  asphyxia.  The  patient's  respirations 
were  about  3  or  4  per  minute;  the  pulse  was  hardly  perceptible,  and 
death  seemed  to  be  imminent. 

We  applied  electric  rhythmic  excitations;  the  patient  revived  defi- 
nitely after  a  period  of  from  25  to  30  seconds.^ 

^  Eobinovitch :     "Eesuscitation  of  a  Woman  in  Profound  Syncope  Caused  by- 
Chronic  Morphin  Poisoning,"  J.  Ment.  Path.,   1909,  8,  No.  4. 


CHAPTER    XVII 

MENTAL    INFLUENCE     AND     HYPNOSIS     IN    ANESTHESIA 

PAET   I 

MENTAL     INFLUENCE     IN     ANESTHESIA 

James  J.  Walsh,  M.D. 

Hypnotism  :  Anesthesia  in  Hypnotic  States ;  Chemical  Anesthetics 
and  Hypnotism;  Advantages  of  Hypnotism  in  Anesthesia;  Hypnotism 
and  Child-birtli ;  Hypnotism  in  Minor  Operations;  Disadvantages  of 
Hypnotism;  Charlatanism  and  Hypnotism. 

Suggestion  :  Suggestion  Instead  of  Hypnotism ;  Psj'chic  Influ- 
ences and  Surgical  Anesthesia;  Local  Anesthesia  and  Mental  Influence; 
Mental  Influence  as  a  Valuable  Auxiliary;  Deep  Breathing  and  Concen- 
tration of  Mind ;  Preliminary  Medication  and  Mental  Influence. 

HYPNOTISM 

Anesthesia  in  Hypnotic  States. — When  hypnotism  developed  in  the 
first  half  of  the  nineteenth  century,  its  influence  on  the  production  of 
insensibility  to  pain  was  noted,  and  attempts  were  made  to  employ  it 
to  lessen  the  awful  tortures  of  surgical  operations  in  the  pre-anesthetic 
days.  About  1840  some  cases  of  surgical  anesthesia  by  hypnotism  were 
reported,  and  there  was  a  discussion  on  the  subject  before  the  Medico- 
Chirurgical  Society  of  London.  In  1843  Elliottson  wrote  a  work  well 
known  to  persons  interested  in  the  influence  of  mind  on  body,  entitled 
"Numerous  Cases  of  Surgical  Operations  Without  Pain  in  the  Mesmeric 
State."  Elliottson's  treatise,  however,  attracted  very  little  attention  in 
England.  There  was  profound  distrust  of  procedures  of  this  kind,  which 
had  been  thoroughly  discredited  by  Mesmer  a  little  earlier  in  the  cen- 
tury, and  which,  at  that  time,  were  usually  called  Mesmerism.  By  1846, 
however,  so  much  had  been  accomplished  that  Sir  John  Eorbes,  a  thor- 
oughly conservative  English  medical  authority,  wrote  in  his  Review  for 
October:  "Indeed,  we  hesitate  not  to  assert  that  the  testimony  is  now 
of  so  varied  and  extensive  a  kind,  so  strong,  and,  in  a  certain  proportion 

644 


MENTAL    INFLUENCE    IN    ANESTHESIA  645 

of  cases,  so  seemingly  unexceptionable,  as  to  authorize  us — nay,  hon- 
estly to  compel  us — to  recommend  that  an  immediate  and  complete  trial 
of  the  practice  be  made  in  surgical  cases." 

Chemical  Anesthetics  and  Hypnotism. — It  was  on  December  17, 
1846,  that  the  news  of  the  employment  of  ether  for  anesthetic  purposes 
reached  England.  On  December  18  the  discovery  was  announced  in 
the  Medical  Gazette.  ISTothing  can  better  show  how  much  attention 
hypnotism  for  anesthesia  had  come  to  occupy  than  the  heading  under 
which  the  anouncement  of  ether  as  an  anesthetic  was  made.  It  was 
"Animal  Magnetism  Superseded."  On  December  19  Lister  operated 
on  a  patient  under  ether,  and  then  all  attention  was  given  to  that  sub- 
ject. As  has  been  pointed  out  by  Hack  Tuke,  it  was  soon  seen  that 
many  sensory  phenomena  which  had  been  noted  under  hypnosis  for 
surgical  purposes,  such  as  calling  out  as  if  in  pain,  sensitiveness,  moan- 
ing, wincing  as  if  from  tenderness,  and  the  like,  were  not,  as  many  had 
supposed  them  to  be  when  they  occurred  in  Mesmeric  patients,  proofs 
of  imposture  or  of  inability  to  control  their  feelings  in  spite  of  their 
wish  to  do  so,  or  of  suppressed  suffering,  but  only  curious  psychic  mani- 
festations that  might  well  occur  in  conjunction  with  a  state  of  complete 
painlessness.  It  is  easy  to  understand,  however,  how,  in  the  progress  of 
chemical  anesthesia  and  the  discovery  of  chloroform  as  an  anesthetic  by 
Simpson,  hypnotism  no  longer  attracted  attention.  Furthermore,  El- 
liottson  unfortunately  allowed  himself,  somewhat  as  did  Luys  in  Paris, 
to  be  deceived  by  some  of  his  subjects.  Later  this  was  discovered,  and 
he  was  compelled  to  resign  as  hospital  attendant. 

Elliottson's  work,  however,  attracted  the  attention  of  Esdaile  in  In- 
dia, who  found,  on  attempting  to  lessen  pain  by  means  of  Elliottson's 
procedures,  that  he  could  actually  produce  complete  analgesia.  This  led 
him  into  a  series  of  observations,  from  which  he  discovered  that  he 
could  perform  all  sorts  of  operations  on  his  Hindu  patients  after  pre- 
liminary hypnotism,  without  any  manifestation  of  pain,  and  he  suc- 
ceeded in  performing  painless  operations  in  many  hundreds  of  cases. 
He  had,  of  course,  a  particularly  favorable  field.  His  patients  were 
devoted  to  him  and  had  the  greatest  confidence  in  his  hypnotic  and  sur- 
gical powers.  They  trusted  him  absolutely.  The  Orientals  have  cer- 
tain mystical  tendencies  that  predispose  them  to  such  concentration  of 
mind  as  keeps  external  sensations  from  annoying  them,  and  they  proved 
especially  susceptible  to  hypnotic  suggestions.  As  a  consequence,  even 
the  most  serious  operations — -amputations,  the  removal  of  stone  from 
the  bladder,  and  even  grave  abdominal  operations — were  performed  un- 
der hypnosis  without  pain,  and  without  any  unfortunate  effects.  Two 
hundred  recorded  operations,  consisting  of  the  removal  of  large  tumors 
weighing  from  10  to  103  pounds,  are  the  best  evidence  of  this. 

Case  Illustration. — The  description  of  one  of  Esdaile's  cases  as  re- 


646  ANESTHESIA 

corded  by  Bramwell  ^  shows  how  much  can  be  done  in  this  way  under 
favorable  conditions.  The  patient  was  a  peasant  suffering  from  a  tumor 
in  the  antromaxillare.  The  tumor  had  pushed  up  the  orbit  of  the  eye, 
filled  up  the  nose,  passed  into  the  throat,  and  caused  an  enlargement  of 
the  glands  of  the  neck.  In  the  hypnotic  condition  the  patient  permitted 
one  of  the  most  severe  and  protracted  operations  in  surgery.  Esdaile 
describes  the  operation  as  follows :  "I  put  a  long  knife  in  at  the  corner 
of  his  mouth,  and  brought  the  point  out  over  the  cheek  bone,  dividing 
the  parts  between;  from  this  I  pushed  it  through  the  skin  at  the  inner 
corner  of  the  eye,  and  dissected  the  cheek  bone  to  the  nose.  The  pres- 
sure of  the  tumor  had  caused  absorption  of  the  anterior  walls  of  the 
antrum,  and,  on  pressing  my  fingers  between  it  and  the  bone,  it  burst, 
and  a  shocking  rush  of  blood  and  matter  followed.  The  tumor  ex- 
tended as  far  as  my  fingers  could  reach  under  the  orbit  and  the  cheek 
bone,  and  passed  into  the  gullet — having  destroyed  the  bones  and  parti- 
tion of  the  nose.  No  one  touched  the  man,  and  I  turned  his  head  in  any 
position  I  desired,  without  resistance,  and  there  it  remained  until  I 
wished  to  move  it  again;  when  the  blood  accumulated,  I  bent  his  head 
forward,  and  it  ran  from  his  mouth  as  if  from  a  spout.  The  man  never 
moved  nor  showed  any  signs  of  life,  except  an  occasional  indistinct 
moan;  but  when  I  threw  back  his  head,  and  passed  my  fingers  into  his 
throat  to  detach  the  mass  in  that  direction,  the  stream  of  blood  was 
directed  into  his  windpipe,  and  some  instinctive  effort  became  necessary 
for  existence;  he  therefore  coughed  and  leaned  forward  to  get  rid  of  the 
blood,  and  I  suppose  that  he  then  awoke.  The  operation  was  finished, 
and  he  was  laid  on  the  floor  to  have  his  face  sewed  up,  and  while  this 
was  being  done  he,  for  the  first  time,  opened  his  eyes." 

Bramwell,  commenting  on  the  case,  says :  "The  patient  afterward 
informed  Esdaile  that  he  did  not  know  he  had  coughed  and  was  quite 
unconscious  up  to  the  termination  of  the  operation."  The  dressings 
were  removed  2  days  afterward,  when  it  was  found  that  the  wounds  had 
healed  by  first  intention.  The  recovery  was  satisfactory.  Such  a  mode 
of  anesthesia  would  seem  eminently  desirable  to  those  who  know  how 
troublesome  are  operations  of  this  nature  upon  the  face,  necessitating, 
as  they  do,  the  continuous  administration  of  the  anesthetic,  and  involv- 
ing the  practical  impossibility  of  securing  healing  by  first  intention,  be- 
cause of  the  manipulation  necessary  for  the  administration  of  the  anes- 
thetic. It  is  interesting  to  note  that  Esdaile's  assistant  had  first  tried 
to  hypnotize  the  patient  and  had  failed.  Esdaile  succeeded  in  bringing 
about  profound  hypnosis  only  after  half  an  hour  of  very  patient  labor. 

Other  cases  not  unlike  this  are  reported  by  Bramwell,  and  there  is  a 
series  of  well-authenticated  cases  from  Braid  and  Bramwell.     It  is  evi- 

^ ' '  Hypnotism,   Its   History,   Practice   and   Theory, "   by    J.    Milne    Bramwell, 
London,  1906. 


MENTAL    INFLUENCE    IN  ANESTHESIA  647 

dent  that,  under  certain  circumstances  and  for  special  patients,  hypno- 
tism may  prove  a  valuable  auxiliary,  and  the  thought  of  its  usefulness  in 
this  regard  should  not  be  put  aside  as  visionary  until  we  have  had  much 
more  experience. 

Advantages  of  Hypnotism  in  Anesthesia. — Bramwell  is  an  enthusi- 
ast in  the  matter,  and  undoubtedly  views  the  subject  much  more  favora- 
bly than  do  many  others.  It  must  not  be  forgotten,  however,  that  in  sci- 
ence negative  observations  are  of  little  value  compared  with  positive 
observations.  Bramwell  has  succeeded  in  securing  results ;  if  others  can- 
not, it  may  very  well  be  because  of  lack  of  confidence  in  themselves,  lack 
of  faith  on  the  part  of  their  patients,  defect  of  technique,  and  want  of 
persistency.  Bramwell  has  summarized  some  of  the  advantages  of 
hypnosis  as  an  anesthetic  as  follows: 

(I)  When  once  deep  hypnosis  with  anesthesia  has  been  obtained,  it 
can  immediately  be  reinduced  at  any  time. 

(3)  Ko  repetition  of  any  hypnotic  process  is  necessary;  the  verbal 
order  to  go  to  sleep  is  sufficient. 

(3)  The  hypnotizer's  presence  is  not  essential.  The  patient  can  be 
put  en  rapport  with  the  operator  by  written  order,  or  by  other  means 
previously  suggested  during  hypnosis. 

(4)  No  abstinence  from  food  or  other  preparation  is  necessary, 

(5)  Nervous  apprehension  can  be  removed  by  suggestion. 

(6)  Hypnosis  is  pleasant  and  absolutely  devoid  of  danger. 

(7)  It  can  be  maintained  indefinitely  and  terminated  immediately 
at  will. 

(8)  The  patient  can  be  placed  in  any  position  without  risk — an 
important  point  in  operations  on  the  mouth  and  throat — and  will  alter 
that  position  at  the  command  of  the  operator.  Gags  and  other  retentive 
apparatus  are  unnecessary. 

(9)  Analgesia  alone  can  be  suggested,  and  the  patient  left  sensitive 
to  other  impressions — an  advantage  in  throat  operations. 

(10)  In  labor  cases  the  influence  of  the  voluntary  muscles  can  be 
increased  or  diminished  by  suggestion. 

(II)  There  is  no  tendency  to  sickness  during  or  after  operation — a 
distinct  gain  in  abdominal  cases. 

(12)  Pain  after  operation  or  during  subsequent  dressing  can  be 
entirely  prevented. 

(13)  The  rapidity  of  the  healing  process,  possibly  as  the  result  of 
the  absence  of  pain,  is  frequently  very  marked. 

Hypnotism  and  Child-birth. — In  a  certain  number  of  cases  hyp- 
notism has  been  used  successfully  for  the  relief  or  even  complete  sup- 
pression of  pains  of  child-birth.  A  number  of  observers,  among  whom 
are  Schrenck-lSTotzing  and  a  number  of  French  observers,  have  reported 
cases  in  which  even  the  pains  of  severe  labor  were  thus  relieved.     There 


648  ANESTHESIA 

is  no  doubt  that  the  mind  can  greatly  influence  the  course  of  labor.  It 
has  often  been  noted  that  when  a  patient  has  expected  a  particular 
physician  in  whom  she  has  confidence,  and  for  some  reason  another 
comes  in  his  stead,  the  labor,  which  may  have  been  progressing  nor- 
mally or  even  rapidly,  becomes  sluggish  or  its  progress  ceases  entirely. 
It  has  been  said  that  insufficient  contractions  of  the  uterus  and  acces- 
sory muscles  can  be  stimulated  by  suggestion,  while  excessive  muscular 
contractions  can  be  diminished  in  this  way.  Fianton  has  even  claimed 
that  he  can  successfully  excite  premature  labor  by  suggestion.  Un- 
doubtedly mental  influence  means  much  in  these  cases.  Probably  the 
persuasion  that  a  definite  time  should  be  the  occasion  for  birth  may 
save  a  woman  from  the  retention  of  the  child  in  utero  for  a  month  be- 
yond the  normal  time,  while  this  delay  may  be  occasioned  by  a  wrong 
persuasion  in  the  matter.  Certainly  the  use  of  suggestion  to  save 
woman  from  many  of  the  troubles  of  the  puerperium  should  not  be 
neglected. 

Hypnotism  in  Minor  Operations. — Many  others  have  employed  hyp- 
notism for  the  production  of  insensibility  to  pain  during  minor  surgical 
operations.  As  we  have  said,  it  was  overshadowed  by  the  newer  anes- 
thetic methods.  Some  devotees  of  hypnotism,  however,  have  continued 
to  practice  surgical  anesthesia  by  hypnotic  methods. 

Disadvantages  of  Hypnotism. — It  should  be  borne  in  mind  that  there 
are  many  drawbacks  to  this  method  of  inducing  anesthesia.  Surgical 
anesthesia  requires  deep  hypnosis.  Only  a  limited  number  of  indi- 
viduals, probably  not  more  than  one  in  ten  (if  that  many),  can  be 
brought  into  such  deep  hypnosis  as  will  allow  of  cutting  operations 
without  pain.  This  is  true  particularly  if  the  operations  are  prolonged. 
The  length  of  the  hypnotic  state  is  not  always  well  under  control  of  the 
operator.  Occasionally  patients  come  out  of  the  hypnotic  state  during 
the  course  of  an  operation;  they  are  then  liable  to  suffer  more  than  if 
this  method  had  not  been  employed  and  to  be  somewhat  uncontrollable. 
Besides,  there  are  psychic  disadvantages.  Occasionally  patients  have 
suffered  very  much  afterward,  as  if  somehow  the  suppressed  pain  pro- 
duced an  exaggerated  reaction.  Occasionally  too  deep  suggestion  has 
left  a  curiously  susceptible  condition,  and  patients  have  suffered  more 
in  the  after-treatment  than  would  otherwise  have  been  the  case. 

As  a  rule,  a  number  of  seances  of  hypnotism  must  be  held,  in  order 
that  the  operator  may  be  assured  that  he  can  produce  a  condition  of 
hypnosis  sufficiently  profound  for  surgical  purposes.  This  has  many 
disadvantages.  A  sort  of  hypnotic  habit  has  been  developed  in  some 
people,  manifesting  itself  during  convalescence,  so  that  almost  any  un- 
usual incident  would  recall  the  hypnotic  state.  As  a  consequence  of  all 
these  disadvantages,  hypnotism  has  never  been  generally  used  for  sur- 
gical anesthesia.    There  is  no  doubt,  however,  that  in  a  great  many  per- 


MENTAL    INFLUENCE    IN    ANESTHESIA  649 

sons  hypnotism  can  be  employed  to  secure  almost  complete  anesthesia 
for  shorter  surgical  operations.  The  pulling  of  teeth,  the  opening  of 
a  boil  or  even  a  carbuncle,  the  dilatation  of  a  sinus,  the  removal  of  a 
wart  or  of  a  small  mole,  or  even  of  a  wen,  may  be  accomplished  in  the 
hypnotic  state.  The  hypnotism  in  these  cases  is  not  something  special 
to  the  operator,  but  is  due  to  the  confidence  that  the  patient  has  in  him, 
so  that,  at  his  persuasion,  the  mind  becomes  concentrated  on  a  single 
thought,  with  the  senses  dulled  except  the  sense  of  hearing,  and  that  re- 
ceives only  the  impressions  that  the  operator  desires  to  give.  Hyp- 
notism is  not  a  mysterious  process,  but  a  state  that  can  be  induced  in 
susceptible  persons  by  anyone  who  has  the  confidence  of  the  subject  and 
sufficient  assurance  in  his  own  power  to  accomplish  it  to  make  the  pa- 
tient accept  his  declaration. 

Charlatanism  and  Hypnotism. — Undoubtedly  some  of  the  minor 
operations  that  are  done  by  wandering  advertising  physicians  who  re- 
move teeth  or  open  boils  or  abscesses  without  pain  are  accomplished  in 
a  state  resembling,  if  not  identical  with,  hypnotism.  In  country  places 
particularly  people  are  likely  to  have  an  exaggerated  sense  of  the 
wondrous  powers  of  men  who  claim  to  have  the  faculty  of  producing  in- 
sensibility to  pain  by  rubbing  something  over  the  part  that  is  to  be  af- 
fected by  the  operation.  They  become  so  much  occupied  with  this 
thought,  and  with  the  positive  assurance  given  them  of  the  painlessness 
of  the  operation,  that  they  feel  very  little  or  no  pain.  The  wonderful 
'^pain  killer"  that  has  been  applied  is  then  sold  to  them,  but  it  practi- 
cally always  fails  to  produce  similar  results  to  those  first  experienced 
when  its  maker  is  not  present  and  producing  a  very  definite  mental 
effect. 

SUGGESTION 

Suggestion  Instead  of  Hypnotism. — In  recent  years  hypnotism  has 
fallen  into  disrepute  once  more,  and  its  dangers  have  come  to  be  em- 
phasized. These  are  mainly  connected  with  frequently  repeated  hypnotic 
seances.  Many  who  are  interested  in  the  influence  of  mind  on  body 
have  come  to  realize,  however,  that  most  of  the  effects  that  can  be  se- 
cured through  hypnotism  can,  with  equal  patience  and  persistence,  and 
with  the  confidence  of  the  physician  and  the  trust  of  the  patient,  be  ob- 
tained by  suggestion  in  the  waking  state.  It  is  probable  that  this  would 
never  be  true  for  complete  anesthesia  such  as  would  permit  the  per- 
formance of  a  serious  surgical  operation.  There  is  no  doubt,  however, 
that  the  operator's  mind  can  to  a  great  degree  influence  the  suscepti- 
bility to  pain,  and  so  predispose  the  patient's  mind  and  preoccupy  his 
attention  that  the  solicitude  before  operation  is  greatly  lessened  and  the 
preliminary  stage  of  excitement  during  inhalation  anesthesia  is  prac- 


650  ANESTHESIA 

tically  obliterated.  This  is  not  of  trifling  importance,  for  it  greatly 
diminishes  the  amount  of  the  anesthetic  necessary  to  produce  complete 
insensibility  to  pain.  It  must  not  be  forgotten  that  the  mortality  after 
operations  in  our  time  is  distinctly  increased  by  the  after-effects  of  the 
anesthetic,  and  that  the  less  of  the  agent  that  is  given  the  better  the 
outlook.  A  careful  application  of  suggestion,  then,  as  an  auxiliary,  may 
not  only  save  the  patient  worry  and  the  lowering  of  resistive  vitality, 
but  may  tend  at  least  to  be  actually  life-saving. 

Psychic  Influences  and  Surgical  Anesthesia. — The  principles  of 
mental  influence  in  the  production  of  absolute  anesthesia  and  hyper- 
esthetic  conditions  have  a  valuable  application  in  surgical  anesthesia. 
If  the  patient's  mind  is  properly  prepared,  if  his  confidence  is  secured, 
if  solicitude  is  removed,  if  anticipation  is  blunted,  then  much  less  of  an 
anesthetic  is  needed  to  bring  the  patient  into  insensibility  to  pain  than 
would  otherwise  be  the  case.  A  terrified,  excitable  patient  requires  a 
large  amount  of  an  anesthetic  that  must  be  administered  in  heavy,  con- 
tinuous doses,  and,  even  with  that,  often  does  not  exhibit  complete  re- 
laxation and  absolute  insensibility.  It  is  extremely  important,  then, 
that  patients  be  assured  as  much  as  possible  with  regard  both  to  the 
operation  and  the  anesthetic  itself.  They  should  not  be  allowed  to  be  in 
or  near  operating  rooms  where  there  is  any  manifestation  of  pain  on 
the  part  of  the  preceding  patient,  nor  in  contact  with  those  who  are 
coming  out  of  the  anesthetic,  nor  near  those  who  are  exhibiting  any 
lack  of  control  during  the  early  administration  of  the  anesthetic.  Sur- 
geons should  bear  this  in  mind,  and  not  discuss  subjects  which  in  this 
excitable  stage  may  unduly  impress  and  perhaps  terrify  the  patients 
about  to  be  anesthetized.  As  far  as  possible  the  anesthetist  should  not 
be  a  stranger  to  them,  or,  if  a  stranger,  should  be  introduced  under  cir- 
cumstances that  impress  them  with  the  idea  that  the  going  under  anes- 
thesia will  be  easy  and  that  there  will  be  absolutely  no  reason  for  solici- 
tude during  its  course. 

Anyone  who  has  seen  a  man  gain  the  full  confidence  of  patients  and 
take  pains  to  reassure  them,  telling  them  soothingly  to  concentrate  their 
attention  on  deep  breathing,  and  controlling  quietly  the  first  sign  of  ex- 
citement, and  bring  them  fully  under  an  anesthetic  without  any  diffi- 
culty and  with  only  a  few  drops  of  the  anesthetic  material,  will  realize 
how  important  the  patient's  state  of  mind  is  in  anesthesia.  It  has 
been  suggested  that  the  patient  should  be  asked  to  put  the  hands  to- 
gether quietly  across  the  chest,  and  that,  whenever  there  is  a  tendency 
to  separate  them,  the  suggestion  should  be  given  to  keep  them  together. 
The  constantly  repeated  suggestion  of  keeping  the  hands  together  and 
breathing  deeply,  if  given  quietly,  so  occupies  the  patient's  attention 
that  the  excitable  stage  of  anesthesia  often  passes  over  unnoticed,  or  with 


MENTAL    INFLUENCE    IN    ANESTHESIA  651 

only  the  beginning  of  movements  of  the  muscles  controlled  at  once  by 
gentle  contrary  suggestion. 

Classes  of  Patients  Where  Psychic  Influences  Ake  Most 
Useful. — This  method  is  particularly  important  for  patients  who  are 
nervous,  excitable,  and  inclined  to  be  terrified  over  the  operation.  Un- 
less negroes  have  complete  confidence  in  the  operator  and  the  anesthetist, 
there  is  almost  sure  to  be  a  disturbing  excited  stage.  On  the  other 
hand,  there  are  men  who  have  the  confidence  of  such  patients  and  are 
able  to  bring  them  under  the  anesthetic  influence  without  any  difficulty. 
The  same  thing  is  true  of  children.  Some  one  whom  the  child  knows 
and  trusts  implicitly,  but  who  is  not  likely  to  grow  excited  or  to  show, 
even  by  the  slightest  sign  in  voice  or  action,  that  they  are  worried,  is 
a  great  help  in  bringing  the  child  under  anesthesia.  The  stroking  of  the 
child's  hands  by  this  person,  and  repeated  suggestions  to  breathe  deeply, 
to  keep  the  hands  together  and  not  to  move  the  feet,  will  usually  bring 
the  little  patient  under  the  anesthetic  without  any  difficuly.  This  rep- 
resents a  real  mental  influence  due  to  suggestion,  and  it  is  of  great  value. 
It  can  be  adapted  to  various  patients  so  as  to  produce  the  best  possible 
effects.  In  its  absence  there  may  be  trouble  and  excitement,  and  force 
may  have  to  be  employed;  the  patient,  in  such  an  event,  is  not  so  well 
disposed  to  resist  the  influence  of  the  shock  of  the  operation.  With  it 
everything  goes  smoothly,  and  a  waste  of  precious  vitality,  often  needed 
for  the  strain  of  the  operation,  is  spared. 

Local  Anesthesia  and  Mental  Influence, — The  varying  phases  of  in- 
terest in  local  anesthesia  illustrate  very  well  how  large  a  role  mental  in- 
fluence plays  in  these  conditions.  Some  surgeons  can  perform  almost  any 
operation  under  local  anesthesia  without  complaint  on  the  part  of  the 
patient.  Others,  who  employ  much  more  of  the  nerve-obtunding  drugs, 
are  imable  to  accomplish  anything  like  the  same  amount  of  surgical 
intervention,  even  this  being  accompanied  by  rather  serious  complaints 
on  the  part  of  the  patient.  Many  a  young  physician  who  has  seen  an 
experienced  surgeon  perform  a  rather  serious  operation  by  means  of  in- 
filtration anesthesia  has  gone  home  impressed  with  the  idea  that  he 
could  surely  do  a  much  simpler  operation  in  the  same  way.  He  has 
been  inclined  to  think  that  the  chemical  agent  used  was  the  most  im- 
portant portion  of  the  anesthesia.  He  may  have  found,  however,  that 
his  patient  complained  very  bitterly.  Often  such  an  experience  has 
been  enough  to  make  him  give  up  the  idea  of  using  local  anesthesia. 
What  he  needed  to  realize,  however,  was  that  the  patient  was  not  so 
deeply  influenced  by  him  as  by  the  more  experienced  surgeon,  and  that, 
as  a  consequence,  even  the  slight  pain  produced,  owing  to  nervous  irrita- 
bility, became  exaggerated  after  a  time,  giving  rise  to  the  patient's  bit- 
ter complaints. 


652  ANESTHESIA 

Importance  of  Personality  of  the  Anesthetist. — The  surgeons 
who  have  reported  success  with  local  anesthesia  have  been  men  of  a 
special  personality  capable  of  attracting  the  confidence  of  patients,  and 
of  making  them  feel  absolutely  sure  of  their  physician's  assurance  that 
there  was  to  be  no  pain.  Schleich  did  much,  some  fifteen  years  ago,  to 
develop  local  anesthesia  by  infiltration  methods.  Numbers  of  physi- 
cians who  visited  him  thought  they  possessed  his  full  secret  when  they 
had  learned  his  technique  and  secured  his  formulae.  Many^  of  them 
found,  however,  that,  while  Schleich's  patients  seemed  to  suffer  no  pain 
even  from  serious  operations,  their  patients  often  sufl^ered  pain  from 
even  trifling  surgical  intervention.  Everywhere  that  local  anesthesia 
was  being  employed  at  that  time  the  personality  of  the  operator  was  the 
most  interesting  feature  of  the  work.  The  mental  element  was  an  essen- 
tial factor  in  the  insensibility  to  pain.  In  this  country  our  local  anes- 
thetists have  been  of  the  same  class. 

Mental  Influence  as  a  Valuable  Auxiliary. — No  matter  what  the 
form  of  anesthesia,  it  is  an  extremely  helpful  auxiliary  to  have  the  mind 
favorably  disposed  toward  it,  and  the  patient  properly  assured  and  con- 
fident of  the  successful  issue  of  both  the  anesthetic  and  the  operation. 
Undoubtedly  many  of  the  adjuncts  of  various  kinds  that  have  been 
introduced,  and  that  for  a  time  were  efficient  in  producing  anesthesia 
without  excitement  in  conjunction  with  ether  and  chloroform,  have 
owed  their  success  more  to  the  influence  on  the  patient's  mind  than  to 
their  own  efficiency.  They  have  come  and  gone,  acquiring  reputations 
and  then  losing  them,  as  remedies  of  all  kinds  have  done  which  affected 
the  mind,  because  they  were  given  with  a  strong  suggestion  that  they 
would  produce  a  definite  effect,  and  this  effect  was  manifested  as  a 
consequence  of  the  suggestion.  Certain  it  is  that  almost  anything  given 
the  patient  with  the  promise  that  it  will  make  the  taking  of  the  anes- 
thetic easier  and  will  do  away  with  its  worst  effects  will  greatly  lessen 
the  stage  of  preliminary  excitement.  Patients  who  have  heard  much 
of  the  awful  choking  and  suffocating  sensation  produced  by  an  anes- 
thetic, and  who  dwell  on  the  thought,  do  not  succumb  to  its  effects  very 
readily,  and  more  of  the  anesthetic  is  generally  required  to  bring  them 
under  its  influence.  Physicians,  as  a  rule,  go  under  anesthesia  badly 
for  this  reason.  Suggestion  works  both  favorably  and  unfavorably,  ac- 
cording to  its  significance. 

Deep  Breathing  and  Concentration  of  Mind. — Hack  Tuke,  in  his 
"Influence  of  the  Mind  on  the  Body,"  ^  records  some  stories  of  anes- 
thesia produced  by  the  thought  on  the  part  of  the  patient  that  he 
or  she  was  inhaling  an  anesthetic.  Such  experiences  are  not  uncommon. 
Every  anesthetist  is  likely  to  have  had  patients  who  began  to  manifest 
symptoms  of  disturbance  of  consciousness  at  least,  if  by  chance  the  in- 

1  Philadelphia,  1889. 


MENTAL   INFLUENCE    IN    ANESTHESIA  653 

haler  without  any  anesthetic  was  placed  over  their  mouths  and  they  were 
told  to  breathe  deeply.  Deep,  rapid  breathing  will  of  itself  produce  cer- 
tain changes  in  the  blood  which  bring  about  a  certain  amount  of  anal- 
gesia ;  and,  if  patients  are  told  to  do  it,  and  have  emphasized  for  them  its 
effect  upon  their  pain  sense,  it  is  rather  easy  to  open  boils  or  abscesses 
with  the  production  of  very  little  pain.  It  is  probable  that  in  all  cases  it 
is  of  advantage  to  properly  compose  the  patient's  mind  and  begin  the 
anesthesia  by  deep  breathing  through  the  inhaler  before  any  anesthetic 
is  put  on  it.  A  few  deep  breaths,  with  the  concentration  of  mind  on  the 
breathing,  and  some  soothing  words,  will  usually  put  a  patient  in  a  bet- 
ter disposition  to  take  the  anesthetic  without  excitement  than  any  pro- 
cedure even  more  complex  than  this. 

Preliminary  Medication  and  Mental  Influence. — Certain  substances, 
opium,  for  instance,  when  used  with  discretion,  seem  to  predispose  the 
patient  to  take  an  anesthetic  without  excitement  and  with  much  better 
control.  If  given  an  hour  before  the  administration  of  an  anesthetic, 
even  a  small  dose  will,  especially  in  conjunction  with  a  proper  reassur- 
ance of  the  patient,  produce  a  state  of  mind  in  which  the  anesthetic 
will  be  taken  without  difficulty.  In  nervous,  excitable  persons  some  such 
treatment  is  advisable  for  the  sake  of  its  good  effects.  Sometimes 
bromids  taken  for  several  days  will  produce  a  more  placid  state  of  mind 
than  would  otherwise  be  the  case.  These  drugs,  however,  will  not  re- 
place the  personal  element  of  strong  mental  influence.  Experience  has 
demonstrated  that  patients  of  the  most  varied  ages,  types,  and  tempera- 
ments go  under  an  anesthetic  without  difficulty  in  the  hands  of  a 
skilled  anesthetist,  while  one  without  skill  required  help  and  produced 
rather  serious  stages  of  excitement  in  exactly  the  same  classes  of  pa- 
tients. This  personal  influence  is  largely  an  individual  matter,  but,  if 
the  influence  of  the  mind  in  the  induction  of  anesthesia  is  properly  rec- 
ognized, it  is  probable  that  much  of  its  valuable  help  can  be  secured  by 
anyone  who  deliberately  tries  to  employ  it  as  an  auxiliary. 


PART    II 

HYPNOSIS   IN   ANESTHESIA 

H.  W.  Frink,  M.D. 

Hypnosis:  The  Different  Degrees  of  Hypnosis  and  Some  of  the 
Phenomena  Accompanying  Them;  Factors  Which  Influence  Suggesti- 
bility; The  Attitude  of  the  Hypnotist;  Methods  of  Inducing  the  State 
of  Hypnosis;  The  Induction  of  Anesthesia. 


654  ANESTHESIA 

The  Different  Degrees  of  Hypnosis  and  Some  of  the  Phenomena 
Accompanying  Them. — Every  person  is  in  some  degree  susceptible  to 
suggestion,  but  hypnosis  cannot  be  induced  in  everyone,  nor  can  all 
hypnotizable  persons  be  influenced  to  the  same  extent.  Three  degrees 
of  influence  or  stages  of  hypnosis  are  described  by  For  el,  while  other 
writers  make  as  many  as  seven  or  eight.  Forel's  classification,  which 
seems  to  be  the  simplest  and  most  practical  of  any,  is  as  follows : 

(1)  Somnolence,  or  Drowsiness. — The  subject  influenced  only 
to  this  degree  experiences  more  or  less  lazy  or  sleepy  feelings.  He  can 
open  his  eyes,  however ;  is  perfectly  conscious  of  all  that  goes  on ;  and,  by 
making  an  efl^ort,  he  can  resist  any  or  all  of  the  hypnotist's  suggestions. 

(2)  Hypotaxis,  Charme,  or  Light  Sleep. — Here  the  subject 
cannot  open  his  eyes.  He  is  aware  of  all  that  takes  place,  but  certain 
suggestions  given  by  the  hypnotist  cannot  be  resisted.  Thus,  when  he 
receives  the  suggestion  that  his  arm  is  stiff,  it  becomes  so,  and  he  is  un- 
able to  bend  it.  If  he  is  told  that  one  of  his  limbs  is  paralyzed  he  cannot 
move  it,  or,  if  told  to  clap  his  hands  together  or  to  perform  any  like 
movements,  and  then  given  the  suggestion  that  he  cannot  stop  these 
movements,  he  is  unable  to  do  so.  In  this  stage  some  sensory  phe- 
nomena, such  as  feelings  of  weight  in  the  limbs,  or  of  itching  or  tickling 
in  the  skin,  etc.,  may  be  produced.  A  touch  of  a  pencil,  for  instance,  is 
felt  to  be  hot,  cold,  or  painful,  according  to  the  suggestion  given.  Some 
degree  of  hypesthesia  and,  occasionally,  visual  or  auditory  hallucina- 
tions may  be  successfully  suggested.  Though  the  subject  is  quiet  and 
appears  to  be  asleep,  there  is  no  amnesia,  and  upon  "awaking"  he  re- 
members everything  that  has  taken  place. 

(3)  Somnambulism,  or  Deep  Sleep. — This  degree  of  hypnosis  is 
characterized  by  the  presence  of  amnesia  for  everything  that  occurs 
during  the  period  of  trance.  In  deep  somnambulism  suggestibility  is 
very  great.  Subjects,  while  en  rappori,  believe  everything  the  hypnotist 
tells  them,  almost  any  conceivable  effect  upon  the  voluntary  muscles  can 
be  produced,  and  even  involuntary  motor  or  secretory  mechanisms  may 
be  influenced  (e.  g.,  sneezing,  defecation,  perspiration,  menstruation, 
etc.).  All  sorts  of  hallucinations,  illusions,  and  delusions  are  produced. 
Thus  a  good  subject  will  accept  suggestions  that  he  is  a  great  orator,  a 
baby,  or  even  an  inanimate  object,  and  he  will  act  the  part  in  a  most 
striking  manner. 

Hyperesthesia,  paresthesia,  or  anesthesia  of  any  of  the  senses  may  be 
induced.  Though,  in  response  to  the  hypnotist's  command,  the  subject 
will  carry  out  the  most  complicated  actions,  if  left  alone  he  appears  to  be 
sound  asleep,  and  orders,  shouts,  slaps,  or  pinches  from  a  third  person 
have  no  apparent  effect  upon  him  either  in  stimulating  him  to  any  ac- 
tivity or  in  arousing  him  from  his  trance.  Nevertheless  the  word 
"awake,"  whispered  by  the  hypnotist,  will  at  any  time  promptly  ter- 


HYPNOSIS    IN    ANESTHESIA  655 

minate  the  sleep.  Suggestions  during  the  trance  may  be  so  given  as  to 
have  their  effect  either  directly  carried  over  into  the  waking  state  or  pro- 
duced after  an  interval  of  waking,  at  a  given  time  or  in  response  to  a 
given  signal  (post-hypnotic  suggestion).  Many  persons  after  having 
once  been  deeply  hypnotized  are  quite  susceptible  in  the  waking  state, 
to  the  suggestions  of  the  hypnotist,  and  various  motor  and  sensory  phe- 
nomena, even  to  surgical  anesthesia,  may  be  induced  while  the  subject 
appears  in  all  other  respects  to  be  entirely  in  his  usual  state  of  mind. 

The  three  stages  of  hypnosis  here  described  show  no  sharp  demarcation 
from  one  another,  and  this  or  any  other  classification  is  purely  arbi- 
trary. There  is  little  similarity  to  the  stages  of  chloroform  or  ether 
anesthesia,  for  a  subject  may  pass  immediately  into  somnambulism 
without  going  through  the  first  or  second  stages  of  infiuence,  or,  in 
other  cases,  in  spite  of  the  most  prolonged  and  painstaking  effort  on 
the  part  of  the  hypnotist,  amnesia  and  the  other  phenomena  of  the  third 
stage  cannot  be  produced.  Generally  speaking,  surgical  anesthesia  is  pos- 
sible only  in  the  third  stage.  Though  a  certain  diminution  of  pain 
sensibility  may  be  produced  in  the  second  stage,  complete  anesthesia  is 
rare,  and  cutting  operations  are  seldom  possible.  To  practically  all 
somnambules  one  can  successfully  suggest  that  the  prick  of  a  pin  will  be 
painless,  but  it  is  quite  a  different  matter  to  c'ause  complete  insensibility 
to  the  cut  of  knife  and  scissors.  In  very  suggestible  subjects  absolute 
anesthesia  can  be  obtained,  and,  either  during  the  trance  or  post-hypnoti- 
cally, really  extensive  surgical  operations  may  be  performed  without  the 
slightest  discomfort  to  the  patient;  but  such  instances  are  uncommon, 
and  in  not  a  few  somnambules  surgical  anesthesia  is  an  impossibility, 
while  upon  others  only  minor  operations  are  possible. 

Whether  or  not  somnambulism  may  be  induced  in  a  given  subject 
depends  in  no  small  degree  upon  the  skill  of  the  hypnotist,  but  to  a 
greater  extent  upon  the  suggestibility  of  the  subject.  Out  of  one  hun- 
dred and  nineteen  cases,  Vogt  obtained  somnambulism  ninety-nine  times, 
hypotaxis  eighteen  times,  and  somnolence  twice.  This  percentage  of 
somnambules  is  very  high,  and  for  the  average  hypnotist  to  equal  this 
record  by  half  would  be  no  small  task.  Different  operators  influence  to 
some  extent  from  80  to  98  per  cent  of  their  subjects,  but  not  more  than 
10  per  cent  of  those  influenced  could  be  rendered  surgically  anesthetic. 

Factors  Which  Influence  Suggestibility. — Of  the  general  factors 
which  influence  suggestibility  age  is  the  most  important.  Children 
under  four  or  five  years  of  age  usually  cannot  be  hypnotized,  but  from 
the  6th  to  the  16th  year  nearly  all  children  are  very  readily  influenced, 
and  a  large  percentage  of  them  can  be  made  somnambulistic.  After  six- 
teen suggestibility  diminishes  very  gradually  up  to  about  the  forty-fifth 
year  and  then  more  rapidly.  As  a  rule,  old  people  are  very  hard  to 
influence  or  are  practically  insusceptible.    Sex  and  nationality  have  very 


656  ANESTHESIA 

little  influence  upon  suggestibility.  Health  is  an  important  factor,  and, 
speaking  in  general,  well  people  are  more  easy  to  hypnotize  than  sick 
ones.  This  is  especially  true  of  mental  health,  and  the  neurasthenic, 
psychasthenic,  and  hysterical  usually  are  resistant  subjects.  Idiots, 
low-grade  imbeciles,  and  most  of  the  insane  cannot  be  hypnotized  at  all. 
Most  writers  believe  that  intelligent  and  educated  people  are  more  read- 
ily influenced  than  the  ignorant  and  stupid.  People  accustomed  to 
obedience,  such  as  soldiers,  servants,  etc.,  seem  to  be  more  susceptible 
than  those  who  are  wont  to  command. 

It  must  be  emphasized  that  there  are  no  means  of  determining  be- 
forehand whether  a  person  may  or  may  not  be  hypnotized  readily,  and  the 
statements  here  made  as  to  suggestibility  in  general  are  subject  to  a 
great  number  of  individual  contradictions.  Subjects  who  present  no 
evident  difference  in  respect  to  age,  education,  temperament,  intelli- 
gence, etc.,  show  great  and  inexplicable  differences  in  suggestibility. 
Thus  one  occasionally  finds  children  who  are  quite  unresponsive,  while, 
on  the  other  hand,  a  subject  who,  according  to  all  expectations,  should  be 
difficult  to  hypnotize  turns  out  to  be  extremely  suggestible.  A  case  in 
point  is  that  of  a  woman  of  about  fifty  years  of  age  whom  I  saw  in  con- 
sultation with  J.  H.  Eichards.  Because  of  her  age  and  the  fact  that  for 
twelve  years  she  had  suffered  from  phobias  and  various  sorts  of  hysteri- 
cal manifestations,  I  thought  that  she  would  prove  a  very  poor  subject. 
As  a  matter  of  fact.  Dr.  Eichards  induced  deep  sleep  at  the  first  at- 
tempt, and  at  a  later  date  W.  C.  Cramp  operated  upon  her  for  ingrow- 
ing toenail  under  hypnotic  anesthesia. 

The  Attitude  of  the  Hypnotist. — It  was  quite  the  custom  among 
many  of  the  early  hypnotists,  as  well  as  some  of  the  later  ones,  to  create, 
by  the  use  of  passes,  magnets,  and  mirrors,  or  by  the  assumption  of 
various  peculiarities  of  voice  and  manner,  an  impression  in  the  mind  of 
the  subject  that  the  hypnotist  either  had  at  his  command  some  mysteri- 
ous forces  or  was  the  possessor  of  peculiar  and  almost  superhuman 
strength  of  will.  Though,  doubtless,  such  methods  might  occasionally 
impress  credulous  individuals  in  a  way  favorable  to  the  induction  of 
hypnosis,  yet,  in  many  more  cases,  an  air  of  mystery  is  apt  to  antagonize 
the  subject  and  to  create  a  feeling  of  fear  or  distrust  which  makes 
hypnotization  difficult  or  even  impossible.  On  this  account  it  is  now 
generally  considered  an  essential  part  of  the  technique  of  hypnotizing 
for  the  operator  to  explain  to  his  subject  that  there  is  no  magic  con- 
nected with  hypnotism,  that  it  is  a  condition  of  mind  into  which  nearly 
all  normal  people  are  capable  of  passing,  and  that  its  successful  induc- 
tion in  no  way  depends  upon  the  operator's  possessing  a  strong  will  or 
the  subject  a  weak  one;  but  merely  upon  the  willingness  and  ability  of 
the  two  persons  to  cooperate  in  carrying  out  a  technique  that  can  be 
learned  by  almost  anyone.    The  subject  is  farther  assured  that  hypnosis 


HYPNOSIS    IN    ANESTHESIA  657 

will  not,  as  is  popularly  supposed,  "weaken  his  will"  or  render  him  re- 
sponsive to  commands  or  requests  which,  in  his  natural  state,  would  be 
strongly  objectionable  to  him. 

In  inducing  hypnosis  or  the  giving  of  suggestions,  some  hypnotists 
use  a  loud,  commanding  tone,  and,  so  to  speak,  bully  their  subjects  into 
the  trance.  Others,  as  does  the  writer,  speak  in  a  perfectly  natural, 
quiet  conversational  tone  and  avoid  any  assumption  of  authority. 
Either  method  is  effective,  and  ordinarily  an  operator  succeeds  best  with 
the  one  more  natural  to  him. 

Methods  of  Inducing  the  State  of  Hypnosis. — A  very  simple  but 
not  particularly  efficient  method  is  that  mentioned  by  James.  "Leave 
the  subject  seated  by  himself,  telling  him  that  if  he  close  his  eyes  and 
relax  his  muscles,  and,  as  far  possible,  think  of  vacancy,  in  a  few 
minutes  he  will  'go  off.'  On  returning  in  ten  minutes,  you  may  find  him 
effectually  hypnotized." 

The  method  of  hypnotizing  employed  by  Bramwell  is  the  same, 
practically,  as  that  used  by  Liebeaut,  Bernheim,  and  many  others.  It 
has,  perhaps,  the  most  general  use  of  any.  Bramwell  does  not  at- 
tempt to  hypnotize  his  subject  at  the  first  sitting,  but  devotes  this 
time  to  making  the  patient's  acquaintance  and  ascertaining  his  atti- 
tude toward  hypnotism.  At  the  same  time  he  endeavors  to  remove 
any  erroneous  ideas  the  patient  may  have,  and  he  refuses  to  make 
any  attempt  to  hypnotize  until  his  patient  is  convinced  of  the  desira- 
bility and  safety  of  the  procedure.  At  the  next  meeting  Bramwell 
addresses  his  patient  as  follows :  "Presently  I  shall  ask  you  to  look  at 
my  eyes  for  a  few  seconds,  when  probably  your  eyelids  will  become  heavy 
and  you  will  feel  impelled  to  close  them.  Should  this  not  happen,  I 
shall  ask  you  to  shut  them,  and  to  keep  them  closed  until  I  tell  you  to 
open  them.  I  shall  then  make  certain  passes  and  suggestions,  but  I  do 
not  wish  you  to  pay  much  attention  to  what  I  am  saying  or  doing,  and, 
above  all,  you  are  not  to  attempt  to  analyze  your  sensations.  Your 
best  plan  will  be  to  create  some  drowsy  mental  picture  and  to  fix  your 
attention  on  that.  You  must  not  expect  to  go  to  sleep.  A  certain  num- 
ber of  hypnotized  persons  pass  into  a  condition  more  or  less  closely  re- 
sembling sleep;  few  do  so  at  the  first  sitting,  however,  and  you  must 
only  expect  to  feel  drowsy  and  heavy." 

After  having  given  these  instructions,  he  places  the  patient  in  a  com- 
fortable chair,  and  darkens  the  room.  Bramwell  continues:  "I  re- 
quest the  patient  to  look  at  my  eyes,  at  the  same  time  bringing  my 
face  slightly  above  and  about  ten  inches  from  his.  The  patient's  eyes 
sometimes  close  almost  immediately.  Should  they  not  do  so,  I  continue 
to  look  steadily  at  him  and  make  suggestions.  These  are  twofold:  the 
patient's  attention  is  directed  to  the  sensations  he  is  probably  experienc- 
ing, and  others  which  I  wish  him  to  feel  are  suggested.     Thus:     '^Your 


658  ANESTHESIA 

eyes  are  heavy,  the  lids  are  beginning  to  quiver,  the  eyes  are  filling  with 
water.  You  begin  to  feel  drowsy;  your  limbs  are  becoming  heavy;  you 
are  finding  it  more  and  more  difficult  to  keep  your  eyes  open,  etc' 
Sometimes  this  produces  the  desired  result;  the  eyes  close  and  the  first 
stage  of  hypnosis  is  induced.  If  this  does  not  take  place,  I  direct  the 
patient  to  close  his  eyes,  and  make  passes  over  the  head  and  face,  either 
with  or  without  contact,  repeating  meanwhile  appropriate  verbal  sug- 
gestions.   This  is  continued  for  half  an  hour." 

The  following  method  is  the  one  generally  employed  by  the  writer. 
It  is  a  combination  of  the  methods  of  Yogt  and  Forel.  Its  chief 
advantage  is  that  it  gives  ample  opportunity  for  "training"  the 
subject. 

The  patient  is  seated  in  an  easy-chair  or  reclines  upon  a  couch.  I 
then  tell  him  to  relax  his  muscles  and  to  make  himself  as  quiet  and 
comfortable  as  possible.  By  lifting  his  hand  and  letting  it  drop,  I  test 
the  muscular  relaxation  and  do  not  proceed  until  it  is  quite  complete. 
Then,  holding  my  fingers  a  short  distance  above  the  patient's  head  and 
in  such  a  position  that  he  cannot  see  them  without  straining  his  eyes  up- 
ward, I  ask  him  to  look  at  them  for  a  few  moments  and  then  to  close 
his  eyes.  I  then  press  with  one  of  my  fingers  well  up  in  the  middle  line 
of  the  patient's  forehead  and  direct  him  to  keep  his  eyes  closed,  but  to 
roll  his  eyeballs  upward  as  if  to  look  at  the  spot  where  I  am  pressing. 
I  then  say  something  to  this  effect:  "You  have  noticed,  probably,  that 
your  eyes  have  begun  to  feel  a  little  tired  and  strained.  While  you  keep 
your  eyes  rolled  up,  you  will  doubtless  find  that  they  tend  to  become 
more  and  more  tired,  that  the  lids  begin  to  feel  heavy,  and,  as  you 
keep  looking  up,  I  think  you  will  notice  that  it  is  harder  for  you 
to  open  your  eyes  than  usual — the  lids  have  a  tendency  to  stick  to- 
gether." Then,  after  lightly  stroking  the  patient's  lids  and  brow  for  a 
moment  with  my  other  hand,  I  say:  "Now  try  to  open  your  eyes 
slowly,  and  see  if  I  am  not  right." 

In  employing  this  technique,  the  hypnotist  takes  advantage  of  a 
physiological  fact  which  is  unknown  to  most  patients.  When  the  sub- 
ject strongly  stimulates  the  third  nerve  in  the  effort  of  straining  the 
eyeballs  upward  with  the  eyelids  closed,  it  is  practically  impossible  for 
him  to  open  his  eyes  without  looking  down.  On  this  account  if,  as  the 
majority  of  people  do,  the  subject  follows  directions  exactly,  and  tries 
to  open  his  eyes  while  his  eyeballs  are  rolled  up,  he  suddenly  discovers 
that  he  cannot  do  so,  and,  unable  to  assign  any  other  cause  for  this  oc- 
currence, he  attributes  it  to  the  hypnotist's  suggestions.  This  apparently 
brilliant  beginning  impresses  the  subject  and  makes  him  think  that  all 
further  suggestions  will  succeed  eqiially  well.  Thus  half  the  battle  is 
won.     It  is  not  necessary  to  test  him  with  his  eyeballs  lowered;  one 


HYPNOSIS    IN    ANESTHESIA  659 

merely  says:  "Yes,  your  eyelids  stick  fast  together;  you  cannot  open 
them;  the  harder  you  try  to  open  your  eyes  the  tighter  they  stick;  this 
is  the  beginning  of  sleep,''  etc. 

In  case  the  subject  fails  to  follow  directions  and  succeeds  in  open- 
ing his  eyes,  I  betray  no  disappointment,  but  say  expectantly,  "What 
did  you  notice?  Your  eyes  did  not  open  easily"  or  something  of  the 
kind,  and,  in  this  way,  try  to  lead  the  subject  into  admitting  that  he 
felt  something.  As  soon  as  I  have  gained  an  admission,  such  as  that  the 
eyelids  "stick  a  little,"  that  he  felt  lazy  about  opening  them,  or  some- 
thing of  the  kind,  I  have  him  close  his  eyes  again  and  repeat  the  pro- 
cedure, adding:  "This  time  your  eyelids  will  stick  harder.  You  may 
notice  that  you  are  becoming  lazy  and  absent-minded,  and  consequently 
adverse  to  making  any  effort,"  etc.  In  this  way  I  endeavor  to  increase 
by  suggestion  whatever  the  patient  admits  he  felt  and,  at  the  same 
time,  to  introduce  new  suggestions.  I  continue  to  repeat  the  operation, 
and,  when  I  see  that  the  subject,  at  each  repetition,  meets  with  greater 
and  greater  difficulty  in  opening  his  eyes,  I  become  more  definite  in 
suggesting,  until,  finally,  I  can  say  positively :  "Your  eyes  now  stick  fast 
together;  you  cannot  open  them  at  all."  While  giving  the  above  sug- 
gestions, I,  at  the  same  time,  throw  out  occasional  hints  to  the  effect 
that  a  lazy,  drowsy  feeling  is  coming  over  the  subject,  and  that  he  is  be- 
ginning to  go  to  sleep. 

This  description  of  beginning  the  seance  will,  I  trust,  make  clear  the 
general  scheme  of  this  method  of  hypnotization,  a  consideration  of 
which  now  follows. 

Introduce  as  Early  as  Possible  Several  Lines  of  Suggestion. — In 
doing  this  the  hypnotist  should  avoid  making  definite  statements  that 
.such  and  such  phenomena  will  appear,  but  should  seek  to  bring  about 
the  beginning  of  the  desired  effects  by  hinting,  verbally  and  otherwise, 
at  their  probable  occurrence.  The  four  lines  of  suggestion  most  con- 
veniently followed  are :  Inability  to  open  the  eyes,  advent  of  drowsiness 
or  sleep,  involuntary  rigidity  of  an  arm,  and  heaviness  of  a  hand. 

To  create  an  expectation  of  drowsiness,  I  tell  the  subject,  before  at- 
tempting to  hypnotize  him,  that  it  is  a  scientific  fact  that,  if  anyone  pre- 
tends to  be  in  a  rage,  he  will  actually  feel  a  little  angry ;  if  he  kneels  as  if 
to  pray,  he  tends  to  feel  devout;  and,  in  the  same  way,  if  the  subject  will 
assume  a  quiet  and  comfortable  position,  close  his  eyes,  and  relax  his 
muscles  as  if  be  were  asleep,  he  may  expect  to  feel  drowsy. 

The  method  of  suggesting  inability  to  open  the  eyes  has  been  indi- 
cated. In  suggesting  rigidity  of  the  arm,  the  limb  is  held  as  in  Figure 
275,  with  elbow  and  wrist  hyperextended.  I  then  bend  his  wrist  very 
slightly  back  and  forth  until  I  feel  a  little  resistance  in  either  the  flexors 
or  extensors.    Here  I  immediately  bend  the  wrist  in  the  direction  neces- 


-660  ANESTHESIA 

sary  to  oppose  this  resistance.  This  gives  the  subject  the  impression  that 
the  muscles  of  his  arm  are  becoming  tense  and  introduces  the  line  of  sug- 
gestion desired.  To  suggest  heaviness  of  the  hand,  I  lift  the  patient's 
hand  and  then  drop  it.  If  his  muscles  are  well  relaxed,  the  hand  falls 
heavily,  and  it  is  easy  for  him  to  be  made  to  believe  that  it  really  feels 
heavier  than  usual.  I  assist  the  impression  by  taking  hold  of  his  wrist 
as  if  to  lift  it,  and  then  letting  it  slip  from  my  fingers  as  if  it  were  very 
heavy. 

Push  the  Suggestion  That  Works  Best  Until  Some  Definite  Effect  Is 
Produced  Which  the  Subject  Cannot  Resist. — When,  either  from  what 
the  subject  says  in  response  to  my  hints  or  from  what  I  observe  (for  in- 
stance, I  may  see  that  the  subject  lifts  his  hand  with  diiJiculty  or  I  may 


Fig.  275.— Suggesting  Rigidity  of  the  Arm. 

feel  that  the  muscles  of  his  arm  contract),  I  conclude  that  one  or  an- 
other line  of  suggestion  is  beginning  to  produce  some  effect ;  I  direct  my 
suggestions  toward  increasing  this  one  effect.  The  more  my  suggestions 
work,  the  more  positive  I  become  in  suggesting  until  I  can  say  with  con- 
viction that  the  efl'ect  I  am  seeking  is  produced  and  that  the  subject 
cannot  raise  his  hand,  bend  his  arm,  or  open  his  eyes,  as  the  case  may 
be.  I  am  always  careful  never  to  commit  myself  to  a  definite  assertion 
unless  I  am  sure  that  the  subject  already  feels  or  will  immediately  feel 
what  I  tell  him.  In  this  way  I  avoid  the  danger  of  his  thinking  that 
this  or  that  suggestion  has  failed  with  him. 

When  One  Phenomenon  Has  Been  Successfully  Suggested,  Employ 
It  in  Producing  New  Ones. — Up  to  a  certain  point  each  suggestion  suc- 
cessfully given  increases  the  subject's  suggestibility  and  makes  him 
more  ready  to  accept  new  suggestions.     Also,  a  new  suggestion  is  more 


HYPNOSIS    IN    ANESTHESIA 


661 


acceptable  if  it  can  be  represented  as  the  result  of  or  dependent  upon 
some  already  induced  phenomenon.  Consequently,  if  I  succeed  in  pro- 
ducing irresistible  heaviness  of  the  subject's  haiul,  I  suggest  that  his 
efforts  to  lift  it  have  made  him  very  tired  and  sleepy,  that  the  feeling 
of  weight  is  extending  from  his  hand  all  over  his  l)ody,  that  even  his 


Fig.  276. — Beginning  of  Sleep  by  Frink's  Method. 


head  is  affected  so  that  it  becomes  heavy  and  drowsy,  and  he  finds  him- 
self going  off  to  sleep.  Or,  if  I  have  made  his  arm  stiff,  one  way  of  put- 
ting him  to  sleep  is  by  telling  him  that  his  arm  is  being  drawn  to  his 
head  as  if  by  a  magnet,  that  the  closer  his  arm  comes  to  his  head  the 
more  sleepy  he  becomes,  and  that  by  the  time  his  arm  touches  his  head 
he  will  be  sound  asleep. 

Endeavor  to  Get  the  Subject  into  the  Third  Stage  of  Hypnosis  as 
Soon  as  Possible,  hut  Terminate  the  Seance  Rather  Than  Give  Non- 
effective Suggestions. — When  I  find  that  a  subject  immediately  accepts 
my  suggestions  and  that  everything  I  tell  him  promptly  produces  the 
desired  effect,  I  keep  on  until  I  have  him  soundly  asleep  and  have  in- 
duced automatic  movements,  anesthesia,  and  other  phenomena  of  the 
third  stage.    But  in  cases  where  the  seance  proceeds  less  smoothly  it  is 


662 


ANESTHESIA 


necessary  to  be  very  cautious  in  suggesting,  for,  if  one  attempts  too  much 
at  one  sitting  and  gives  suggestions  that  do  not  take  effect  imme- 
diately, the  subject  gets  the  impression  that  these  suggestions  will  con- 
tinue to.be  unsuccessful.  Such  an  impression  is  difficult  to  remove,  and 
operates  as  a -barrier  against  further  progress  in  that  particular  direc- 
tion. On  this  account  I  content  myself  with  what  result's  I  can  obtain 
from  perfectly  safe  suggesting  and  terminate  the  sitting  as  soon  as  I 


1 

1 

i 

Fig.  277. — Beginning  of  Sleep  by  Feink's  Method. 


find  myself  on  dangerous  ground.  To  do  this  one  need  only  say  to  the 
subject:  "You  are  waking  up  now/'  or,  "When  I  have  finished  count- 
ing ten,  you  will  be  perfectly  wide  awake." 

After  Each  Sitting  Ascertain  Exactly-  What  the  Subject  Experi- 
enced and  Plan  the  Suggestions  to  Be  Given  at  the- Next  Sitting  on  the 
Basis  of  This  Information. — When  the  subject  awakes,  I  ask  him  to 
describe  in  detail  everything  he  experienced,  and  lead  him  on  with  ap- 
propriate questions  if  necessary.  In  this  way  I  learn  the  extent  and  na- 
ture of  the  effect  that  each  of  my  suggestions  had  upon  him,  and  at  the 
next  seance  I  follow  up  those  that  promise  well,  and  avoid  the  ones  that 


HYPNOSIS    IN    ANESTHESIA  663 

are  ineffective.  At  the  same  time,  if  the  subject's  nervousness,  curiosity 
or  some  misconception  has  interfered  with  his  going  to  sleep,  this  will  be 
disclosed  and  can  be  dealt  with.  In  addition,  any  undesirable  auto-sug- 
gestions that  may  have  formed  are  brought  to  light,  and  may  be  over- 
come before  they  can  do  any  harm.  It  will  be  found  that  some  patients 
will  feel  a  certain  sort  of  pride  if  they  have  been  resistant  to  suggestion. 
One  may  then  call  their  attention  to  that  fact,  show  them  that  the  ability 
to  resist  need  cause  them  no  conceit,  and  thus  prevent  further  trouble 
from  such  a  source.  With  some  patients  it  may  be  noticed  that,  though 
by  suggestion  an  arm  may  be  made  perfectly  rigid,  yet  as  soon  as  the  hyp- 
notist says  "You  cannot  bend  your  arm,"  the  reverse  of  the  desired  re- 
sult is  obtained  and  the  limb  is  promptly  bent.  These  are  persons  who 
resent  what  they  consider  an  attempt  to  deprive  them  of  the  "freedom 
of  the  will,"  and  in  dealing  with  them  it  is  better  to  give  such  sugges- 
tions as  "You  will  feel  unwilling  to  bend  your  arm;  the  effort  is  a  disa- 
greeable one,"  etc.,  until  when  it  is  perfectly  clear  that  the  subject  has 
attempted  to  bend  his  arm,  but  without  success,  one  can  then  say,  "You 
cannot  do  it," 

At  Subsequent  Seances  Continue  the  Subjects  Training  Until  the 
Different  Phenomena  of  the  Third  Stage  May  Be  Induced  Beadily  or  the 
Impossibility  of  Their  Induction  is  Demonstrated. — Subjects  who  are  in- 
fluenced only  slightly  in  the  first  or  second  seance  may  often  be  made 
quite  susceptible  by  careful  training.  An  effect  once  produced  on  a  given 
subject  can  always  be  reproduced  without  difficulty,  so  that  at  one  seance 
it  requires  only  a  few  moments  to  bring  about  the  same  degree  of  hypno- 
tization  that  existed  in  the  preceding  one.  At  each  sitting,  therefore,  the 
hypnotist  can  begin  where  he  left  off  at  the  preceding  one,  and  continue 
by  pushing  those  lines  of  suggestion  which  appear  promising.  Whatever 
that  subject  admits  of  having  felt  at  the  preceding  sitting,  the  hypnotist 
endeavors  to  increase  by  further  suggestions,  and  whenever  any  definite 
phenomenon  is  successfully  induced  it  is  employed  in  furthering  some 
partly  successful  line  of  suggestion  or  in  introducing  a  new  one.  In  this 
way,  by  carefully  analyzing  the  results  of  previous  sittings  and  proceed- 
ing cautiously,  one  may  change  slight  hypotaxis  to  complete  hypotaxis, 
and  then,  by  gradually  suggesting  amnesia,  convert  this  stage,  in  turn, 
into  somnambulism.  For  instance,  when  a  subject  tells  me  that  during  a 
sitting  he  felt  drowsy,  lazy,  and  absent-minded,  I  suggest  at  the  early 
part  of  the  next  seance  that  he  feels  so  lazy  and  absent-minded  as  to  pay 
little  attention  to  what  I  am  saying.  Later  in  the  seance  I  tell  him  that 
he  has  been  so  inattentive,  because  of  lazy  and  drowsy  feelings,  that 
when  he  awakes,  he  will  experience  some  difficulty  in  recalling  all  that  I 
have  said  to  him.  If,  at  the  close  of  the  seance,  I  find  that  my  sugges- 
tions have  had  the  desired  effect,  then,  at  the  next  meeting,  I  suggest 
still  greater  drowsiness  and  inattention,  and  greater  consequent  diifi- 


664 


ANESTHESIA 


culty  in  remembering  in  the  waking  state  what  has  occurred.  At  subse- 
quent sittings  I  continue  in  the  same  way  until  complete  amnesia  is  pro- 
duced. If,  in  five  or  six  sittings,  deep  hypotaxis  has  not  been  produced, 
it  is  generally  certain  that  surgical  anesthesia  is  impossible,  and  therefore 
further  attempts  are  practically  useless. 

In  any  case  where  operation  is  contemplated,  the  hypnotist  should 
arrange  to  see  the  patient  at  least  half  a  dozen  times  before  the  date  of 
operation. 

The  Induction  of  Anesthesia. — In  hypnotizing  with  a  view  toward 
surgical  anesthesia,  it  is  best  not  to  run  the  risk  of  failure  by  beginning 


1 

Mm 

1 

1 

■ 

H 

f 

'>     --T 

***^"*'^^ 

^^^I^H 

p 

w 

J 

^s 

t 

V 

1 

»»  ' 

^H 

Fig.  278. — Induction  of  Anesthesia. 


to  suggest  anesthesia  too  soon.  One  should  first  get  the  subject  into  a 
state  of  somnambulism,  or,  if  this  cannot  be  done,  into  as  deep  hypotaxis 
as  possible.  Then  one  may  begin  by  closing  the  subject's  hand  and  pro- 
ducing rigidity  of  the  whole  arm.  The  subject  is  then  told  that  the 
contraction  of  the  hand  and  arm  muscles  begins  to  impede  the  circula- 
tion in  his  hand,  in  consequence  of  which  he  will  probably  become  aware 
of  a  feeling  of  numbness  in  that  region.  He  is  then  informed  that  in 
order  to  test  this  numbness  the  hypnotist  will  prick  the  back  of  the  hand 
with  a  pin  and  that  the  pin  will  feel  less  sharp  than  usual.  Instead  of 
using  a  pin,  however,  the  hypnotist  touches  the  subject's  hand  with  a 
sharpened  match  or  a  toothpick.  If  this  works  well,  and  the  subject 
seems  to  believe  that  a  pin  has  been  used,  greater  diminution  of  sensi- 
bility is  then  suggested,  and  a  real  pin  is  then  employed,  though  very 
lightly.     The  hypnotist  continues  in  the  same  manner,  suggesting  in- 


THERAPEUTIC   USES    OE   INHALATION    ANESTin:TI(;S     665 

creasing  hypalgesia,  and  applying  the  pin  with  more  and  more  force 
until  even  a  vigorous  thrust  causes  the  subject  no  pain.  After  this  it  is 
well  to  suggest  that  not  only  is  the  pin  thrust  entirely  painless,  but  that 
it  is  not  felt  at  all — that  is,  that  the  part  is  both  analgesic  and  anesthetic 
— "perfectly  numb  and  dead,  like  a  piece  of  rubber." 

When  anesthesia  or  analgesia  has  been  successfully  suggested  in  one 
part  of  the  body,  it  is  always  easy  to  reproduce  it  in  any  other  part, 
and  for  so  doing  the  preliminary  suggestion  of  rigidity  or  other  phe- 
nomena is  unnecessary. 

In  any  case  where  an  operation  is  contemplated  the  hypnotist  should 
assure  himself  that  he  has  the  subject  well  under  control,  that  anes- 
thesia can  be  produced  both  promptly  and  certainly,  and  that  it  is  suffi- 
ciently deep.  The  depth  of  anesthesia  should  be  put  to  rather  severe 
tests,  such  as  thrusting  pins  into  the  finger  tips  (with  due  care  to  avoid 
infection)  or  by  touching  the  cornea  after  having  suggested  insensibility 
of  that  part.  Before  the  operation,  appropriate  suggestions  should  be 
given  with  a  view  toward  relieving  the  patient's  mind  of  any  anxiety 
or  dread  in  regard  to  it  and  its  consequences.  The  whole  matter  should 
be  treated  rather  lightly,  as  if  there  could  be  nothing  to  fear  and  every- 
thing was  sure  to  go  smoothly. 

At  the  time  of  operation  the  patient  may  be  placed  upon  the  table 
and  hypnotized  there,  but  it  is  preferable  to  induce  the  hypnosis  in  an 
adjoining  room  and  either  let  the  patient  walk  or  be  carried  to  the 
table  while  in  the  hypnotic  state.  In  any  case,  for  the  patient  to  see  a 
great  display  of  knives,  scissors,  and  other  instruments  is  decidedly  un- 
desirable. During  the  operation  the  hypnotist  should  remain  with  the 
patient,  and  from  time  to  time  suggest  that  he  continue  to  sleep  quietly, 
that  the  field  of  operation  is  entirely  without  sensation,  and  that  every- 
thing is  going  on  nicely.  The  operating  surgeons  had  best  avoid  refer- 
ences to  cuts,  blood,  and  other  matters  which  might  tend  to  have  a  dis- 
quieting effect  upon  the  patient,  who,  though  apparently  in  profound 
slumber,  is  not  entirely  unsusceptible  to  external  influences.  When  the 
operation  is  finished,  before  awaking  the  patient,  it  is  well  to  sug- 
gest that  even  in  the  waking  state  his  wounds  will  cause  him  no  pain 
and  that  the  necessary  dressings  will  give  rise  to  no  discomfort.^ 

1  For  other  considerations  of  hypnotic  therapeutics,  see  Tuke :  ' '  Treatment 
by  Hypnotism  and  Suggestion,"  5th  ed.,  London,  1907;  Ford:  "Hypnotism  and 
Psychotherapy ' ' ;  Hilzer :  ' '  Hypnosis  and  Suggestion ' ' ;  Bernheim :  ' '  Suggestive 
Therapeutics ' ' ;  Moll :  ' '  Hypnotism ' ' ;  Quackenbos :  ' '  Hypnotic  Therapeutics 
in  Theory  and  Practice." 


CHAPTEE    XVIII 

THEEAPEUTIC    USES    OF    INHALATION    ANESTHETICS 

Anesthetic  Treatment  for  Special  Conditions:  In  Eenal  and 
Biliary  Colic;  In  Acute  Pain  or  Shock;  In  the  Passage  of  Eenal  or 
Biliary  Calculi ;  In  Extreme  Irritability  of  the  Central  Nervous  System ; 
Convulsions  of  Infancy  and  Childhood;  Puerperal  Eclampsia;  In 
Anemic  Convulsions;  Convulsions  and  Seizures  Depending  Upon  Poi- 
soning, and  Cerebral  Diseases ;  Use  in  Diagnosis ;  Insomnia  or  Extreme 
Eestlessness ;  Acute  Mania;  Nitrous  Oxid  and  Oxygen;  Some  Miscel- 
laneous Applications  of  Ethyl  Chlorid. 

Other  Uses  of  Agents  Employed  in  the  Administration  of  An- 
esthetics :  Ether  in  the  Treatment  of  Infections ;  Ether  Irrigation  of 
the  Abdomen. 

ANESTHETIC    TREATMENT    FOR   SPECIAL   CONDITIONS 

Anesthesia  has  been  used  sporadically  and,  in  some  few  instances  and 
localities,  regularly  for  special  conditions  or  for  diseases  not  yielding  to 
surgical  operations. 

In  Renal  and  Biliary  Colic. — In  renal  and  biliary  colic  and  for 
similar  acutely  painful  seizures  it  has  been  used  with  great  success. 
Now  that  the  analgesic  stage  of  all  anesthetics,  especially  of  nitrous 
oxid  and  oxygen,  is  more  clearly  recognized,  it  is  probable  that  anes- 
thesia will  be  used  more  frequently  than  ever  before  for  conditions  just 
stated  and  for  similar  conditions.  A  patient  in  an  acute  seizure  of 
renal  colic,  who  might  seriously  object  to  being  anesthetized  to  the  sur- 
gical stage,  would  embrace  the  opportunity  of  the  analgesic  stage  of  any 
anesthetic. 

In  Acute  Pain  or  Shock. — In  cases  of  acute  pain  or  shock  it  is  used 
for  temporary  relief,  not  with  the  idea  of  curing,  but  simply  to  afford 
time  for  recovery  to  take  place  without  pain.  When  anesthetics  are 
given  for  the  analgesic  qualities  alone  they  should  be  employed  only 
under  the  direct  supervision  of  a  physician.  If  cyanosis  or  unconscious- 
]iess  appear,  the  agent  should  be  withdrawn,  to  be  reapplied  again  solely 
for  the  relief  of  pain. 

666 


THERAPEUTIC   USES    OF   INHALATION   ANESTHETICS     667 

In  the  Passage  of  Renal  or  Biliary  Calculi. — In  the  passage  of  renal 
or  biliary  calculi,  chloroform  or  ether  by  the  drop  method  on  gauze  or 
a  handkerchief  affords  speedy  relief;  also  in  the  crises  of  locomotor 
ataxia. 

In  Extreme  Irritability  of  the  Central  Nervous  System. — Wher- 
ever extreme  irritability  of  the  central  nervous  system  exists,  as  in 
tetanus,  strychnin  poisoning,  or  convulsive  affections,  chloroform  to  the 
second  stage  will  easily  relieve  suffering  without  affecting  the  conscious- 
ness. Hewitt  records  one  case  of  a  child  kept  more  or  less  under  the  in- 
fluence of  chloroform  for  thirteen  days,  one  hundred  ounces  being  used. 
It  is  necessary  to  administer  the  anesthetic  only  to  the  point  where  mus- 
cular spasm  subsides,  when  it  is  discontinued.  The  anesthetic  is  to  be 
reapplied  only  when  tetanic  spasm  is  imminent.  If  the  rigidity  is  con- 
tinuous the  administration  must  be  maintained  until  signs  of  the  rigid- 
ity disappear. 

It  is  unnecessary  to  state  that,  except  in  the  presence  of  urgent  indi- 
cations, these  agents  should  not  take  the  place  of  morphin  or  opium. 
When,  despite  the  use  of  morphin  or  opium,  acute  pain  persists,  chlo- 
roform or  ether  may  be  administered  for  short  periods  to  supplement  the 
action  of  these  drugs. 

Convulsions  of  Infancy  and  Childhood. — Convulsions  of  infancy 
and  childhood  are  easily  and  safely  treated  with  pulmonary  anesthetics, 
administered  to  the  analgesic  stage.  Ethyl  chlorid  is  preferred,  because 
its  analgesic  stage  is  longer  than  that  of  any  other  inhalation  anes- 
thetic, and  because  it  is  the  preferable  anesthetic  for  children,  in  the 
opinion  of  many  anesthetists. 

Puerperal  Eclampsia. — Chloroform  has  been  used  for  a  number  of 
years  for  puerperal  eclampsia.  Care  must  be  taken,  however,  if  the  pa- 
tient is  cyanosed.    In  these  cases  ether  is  the  safest  drug. 

In  Anemic  Convulsions,  Convulsions  and  Seizures  Depending  Upon 
Poisoning,  and  Cerebral  Diseases. — In  anemic  convulsions,  convulsions 
and  seizures  depending  upon  poisoning,  and  cerebral  diseases  it  is  better 
to  use  nitrous  oxid  and  oxygen,  with  a  nasal  inhaler,  for  the  analgesic 
effect  than  to  use  chloroform  or  ether,  especially  chloroform,  inasmuch 
as  these  latter  drugs  in  themselves  sometimes,  under  certain  conditions, 
induce  serious  after-effects. 

Use  in  Diagnosis. — General  anesthesia  is  frequently  employed  to 
produce  muscular  relaxation  where  diagnosis  of  certain  conditions  is 
doubtful.  The  selection  of  the  anesthetic  in  these  instances  would  de- 
pend upon  the  conditions  already  stated.  Unless  contraindicated, 
nitrous  oxid  and  oxygen  is  the  best  agent  for  such  conditions  as  'Tiys- 
terical  contractions,"  phantom  tumors,  and  malingering. 

Insomnia  or  Extreme  Restlessness. — In  insomnia  or  extreme  rest- 
lessness morphin  and  similar  drugs  are  often  ineffectual.     The  patient 


668 


ANESTHESIA 


may  be  in  such  a  condition  that  the  usual  measures  necessary  to  pro- 
duce a  quiet  state,  such  as  warm  baths,  massage,  etc.,  caimot  be  used 
except  to  very  great  disadvantage.  Under  these  circumstances  it  is  per- 
fectly justifiable  to  produce  anesthesia  and  to  inaugurate  the  necessary 
remedial  procedures.  Mortimer  ^  treated  a  vigorous  man  who  had  had 
no  sleep  for  many  days  and  nights  in  spite  of  various  hypnotics.  The 
anesthetic  was  administered,  and  the  patient  remained  asleep  for  four 
hours.  By  giving  a  little  more  anesthetic  at  longer  intervals  the  patient 
remained  asleep  for  two  hours  longer.  The  rest  of  the  night  he  re- 
mained quiet  instead  of  wandering  about.  The  next  morning  he  was 
rational,  had  a  bath,  and  ate  a  good  breakfast.  He  slept  most  of  the 
day  and  the  following  night,  awakening  quite  recovered  on  the  second 
morning. 

Acute  Mania. — In  cases  of  acute  mania,  either  temporary  or  recur- 
rent, if  the  condition  is  apparently  dependent  upon  no  perceptible  or 


A. 

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Fig.  279. — Anesthesia  in  a  Case  of  Acute  Mania. 


organic  lesion,  it  would  seem,  theoretically  at  least,  that  general  anes- 
thesia Avould, — in  connection  with  other  remedies  before,  during,  and 
after, — tend  to  lessen  or  shorten  the  usual  period  in  which  the  patient 
may  have  to  be  confined. 

Anesthetics  may  be  given  with  less  danger  for  therapeutical  pur- 
poses than  when  surgical  interference  is  necessary. 

The  first  case,  as  far  as  we  are  aware,  in  which  an  anesthetic  was 
given  for  the  definite  purpose  of  attempting  to  affect  favorably  the 
brain  cells  without  injuring  the  body  occurred  at  the  instigation  of  one 
of  us  (J.  T.  G.)  in  March,  1913,  Dr.  Swepson  J.  Brooks  and  Dr.  T. 
Drysdale  Buchanan  associated.  The  case  was  one  of  mania  of  ten  or 
twelve  years'  standing.    It  is  given  in  full  to  show  that  a  patient  may  be 

'Mortimer,  J.  D.:     Brit.  Med.  J.,  Jan.  7,  1899. 


THERAPEUTIC   USES    OF   INHALATION   ANESTHETICS     669 

successfully  and  easily  anesthetized  for  a  number  of  hours  without  com- 
plications or  shock  resulting  therefrom.  The  case  is  suggestive  of  great 
possibilities  in  psychiatry,  and  is  given  here  primarily  for  that  reason. 

The  patient  was  in  full  surgical  anesthesia  at  10  o'clock,  and  the 
anesthetic  was  discontinued  at  4 :30  p.  m.,  the  patient  being  practically 
under  the  anesthetic  for  six  and  one-half  hours.  The  result  was  entirely 
negative,  as  far  as  affecting  the  patient's  condition  favorably.  It  was 
satisfactory  from  an  anesthetic  standpoint.  The  patient  came  out  of 
the  anesthesia,  and  was  entirely  rational,  with  absolutely  no  unpleasant 
symptoms  of  any  kind.  The  temperature,  pulse,  respiration,  and  blood 
pressure  were  taken  at  regular  intervals,  and  the  chart  (Fig.  279) 
shows  the  result.  The  narcosis  was  started  with  one-quarter  of  a  grain 
of  morphin  with  l/150th  grain  of  atropin  at  9  o'clock.  The  pulmonary 
anesthesia  was  commenced  with  chloroform  at  9  :55  by  the  drop  method. 


Hour 

Temp. 

Pulse 

Reap. 

B.P.  1 

Sleep! 

Stim. 

Medicine 

Nourish- 
ment 

Remarks 

A.M. 

8.— 

9  30 

(Enema) : 

Saline  Glucose  I  i 

O.i 
(per  Hypo) : 
Morph.  Sulph.  gr.  { 
Atrop.  gr.  jIjs 

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99.2 

108 
76 

150 

amination. 

10  05 

ed  (drop). 

10.15 

10.20 

90 
120 

96 
96 
96 
96 

(drop). 

10.25 

10.30 

24 
24 
24 
24 

ministered     (vapor). 

10.3i 

11. — • 

11. OS 

110 

11.20 

Slight  snore — lid  reflex 
— pupil  slightly  dil. 
■ — eyeballs  rolling. 

11.30 

'99.'8 

96 
96 

24 
24 

110 

98 

11.45 

Slight  per.spiration — 
breathing  easy. 

Pt.  warm  but  not  per- 
spiring. 

12.15 

96 
102 

102 

102 
96 
96 
96 

102 
96 

112 
96 

108 

24 
24 

24 

24 
24 
24 
24 
30 
30 
24 

100 
100 

lOOi 

100 
100 
115 
312 
114 
114 
112 

12.30 

Slight  perspiration — 
eyeballs  rolling. 

12.45 

P.M. 
1. — 

do. 

1.15 

do 

1.30 

do. 

1.45 

2.10 

2.20 

2.40 

3.10 

(Enema) : 
Olive  Oil 

3.40 

30 

116 

Massage — Alcohol  rub. 

3.45 

4.00 

99.8 

ioo" 

108 
108 
102 
120 

1 

30 
30 
24 
30 

114 
120 
118 
120 

4.15 

Slight  perspiration. 

4.30 

4.45 

Amt.  Ether  used  5ix 

670  ANESTHESIA 

and  was  gradually  changed  to  ether  by  the  drop  method.  At  10  o'clock 
the  patient  was  in  full  surgical  anesthesia,  and  at  10  :35  oxygen  and  ether 
by  the  vapor  method  were  substituted.    This  was  continued  to  the  end. 

In  acute  mania  or  other  mental  condition  the  alimentary  canal 
should  be  thoroughly  evacuated,  and  when  the  patient  is  under  the 
anesthetic  lecithin,  olive  oil,  and  saline  should  be  continuously  admin- 
istered with  the  idea  of  having  enough  lecithin  absorbed  to  affect  the 
brain  cells  favorably.  The  patient  should  be  given  enough  morphin 
toward  the  close  of  the  pulmonary  anesthetic  to  continue  sleep,  so  that 
he  will  awake  in  as  nearly  a  natural  manner  as  possible.  The  table  on  the 
preceding  page  and  chart  (Fig.  279)  show  the  result  of  this  anesthesia. 

Nitrous  Oxid  and  Oxygen. — Under  the  influence  of  nitrous  oxid 
with  20  per  cent  oxygen,  Klikowitsch  ^  found  in  the  majority  of  healthy 
individuals  accelerated  cardiac  contractions,  diminished  pulse  waves, 
rarer  and  deeper  inspirations.  In  cases  of  weakened  heart  action  an 
unfavorable  influence  upon  the  heart  not  only  failed  to  occur,  but  a 
favorable  effect  was  actually  demonstrable.  The  cardiac  contractions, 
while  somewhat  diminished  in  number,  were  increased  in  efficiency. 
For  these  reasons,  as  well  as  on  account  of  the  beneficial  influence  on 
attacks  of  angina  pectoris,  on  vomiting  and  cough  of  reflex  origin,  Kli- 
kowitsch employed  nitrous  oxid  for  therapeutic  purposes. 

Some  Miscellaneous  Applications  of  Ethyl  Chlorid.^ — To  Differ- 
entiate Betv^een  a  Neuralgia  op  Central  and  One  of  Periph- 
eral Origin. — The  theory  is  that  if  the  lesion  be  central  no  inter- 
ference along  the  course  of  a  centripetal  nerve  will  alter  its  manifesta- 
tion ;  while  if  the  trouble  is  with  terminal  nerves,  when  communicatien 
between  the  periphery  and  the  centers  is  cut  off,  all  pain  will  disappear. 

The  method  is  to  freeze  the  tissues  between  the  apparent  lesion  and 
the  spinal  canal  or  cranium  either  by  freezing,  as  done  for  local  anes- 
thesia, or  by  "reinforced  freezing,^'  i.  e.,  by  injecting  a  quantity  of  dis- 
tilled water  beneath  the  skin  over  the  part  to  be  frozen  or  directly  into 
the  tissue  until  an  appreciable  bulging  is  produced,  and  then  directing 
the  spray  of  ethyl  chlorid  on  this  spot.  The  water  will  become  ice, 
and  the  deeper  tissues  will  be  frozen  or  thoroughly  chilled.  "Coin" 
freezing  is  accomplished  by  placing  a  coin  of  suitable  size  and  wet  with 
water  on  the  skin  and  spraying  ethyl  chlorid  on  it,  when  "a  congelation" 
less  severe  than  reinforced  freezing,  more  severe  than  ordinary  cutaneous 
congelation  and  one  more  accurately  localized  is  obtained. 

To  Differentiate  Neuritis  from  Neuralgia. — "Neuralgia  of  an 
accessible  nerve  treated  by  freezing  near  its  point  of  exit  and  failing  to 
yield  to  repeated  applications  of  the  spray  is  not  a  veritable  neuralgia, 
but  a  neuritis  or  a  complicated  neuralgia." 

^Quoted  by  Brunn:     "Die  Allgemeine  Narkose, "  1913,  325. 

^Abrams:     Am.  Med.  Surg.  Bull,  Dec.  15,  1895,  1487-1490. 


THERAPEUTIC  USES   OF  INHALATION  ANESTHETICS    671 

As  A  Means  of  Localizing  Pain. — If  the  area  of  pain  is  large,  or 
there  are  many  painful  points,  the  pain  will  not  cease  until  the  exact 
spot  of  origin  is  frozen.  In  this  way  Abrams  has  discovered  out  of 
many  cicatrices  the  one  causing  pain,  a  small  neuroma,  and  a  carious 
tooth  not  otherwise  suspected. 

To  Differentiate  Many  Neuralgic  Affections  of  the  Head 
and  Thoracic  and  Abdominal  Parietes  from  Visceral  Diseases. — 
For  this  freezing  is  usually  necessary  along  the  intercostal  nerves  at 
their  exit  from  the  vertebrae.  In  this  way  symptoms  that  have  been  or 
could  be  interpreted  as  disease  of  some  viscus  have  been  referred  to  their 
true  origin. 


OTHER  TJSES  OF  AGENTS  EMPLOYED  IN  THE  ADMINISTRATION 

OF  ANESTHETICS 

Reference  (Chapter  II,  p.  91)  has  been  made  to  the  use  of  vari- 
ous agents  which  have  been  found,  from  laboratory  experimentation 
and  clinical  experience,  to  modify  the  action  of  inhalation  anesthetics. 

Reference  will  be  found  in  Chapter  XV,  p.  598,  to  the  use  of  ether 
as  an  antidote  to  the  various  agents  employed  for  purposes  of  spinal 
analgesia. 

Ether  in  the  Treatment  of  Infections. — We  come  now  to  the  con- 
sideration of  ether  in  the  treatment  of  various  infections.  While  this 
may  be  said  to  be  apart  from  the  subject  of  anesthesia,  it  has  a  practi- 
cal bearing  with  which  the  anesthetist  should  be  familiar. 

Souligoux  ^  has  habitually  and  successfully  employed  ether  in  the 
treatment  of  peritoneal  infections.  He  was  led  to  this  in  1891  by  the 
following  observation :  In  his  service  as  an  interne,  with  Leport,  he  was 
in  charge  of  a  man,  both  of  whose  legs  had  been  crushed  by  a  heavily 
loaded  truck.  The  legs  were  reduced  to  a  mass  with  crushed  bones,  which 
protruded  from  the  midst  of  the  large  wounds,  and  there  seemed  nothing 
left  but  a  double  amputation  at  the  thigh,  to  which  the  patient  refused 
to  submit.  Souligoux  carefully  cleansed  the  wounds  and  poured  in  a 
liberal  supply  of  ether,  after  which  the  two  legs  were  put  up  in  plaster. 
To  his  extreme  astonishment,  no  infection  occurred,  and  the  patient's 
legs  were  preserved.  He  believed  this  to  be  due  to  the  ether,  which  is 
very  volatile  and  which  had  penetrated  into  all  the  corners  and  irregu- 
larities of  the  wounds,  thus  permitting  their  disinfection.  Since  that 
time  he  has  washed  all  wounds  with  ether,  and  employs  ether  also  for  all 
superficial  infections,  lymphangitis,  erysipelas,  etc. 

Mode  of  Application. — The  mode  of  application  is  as  follows :    In 

1  Souligoux :      ' '  Sur  1  'emploi  de  1  'ether  dans   les  infections, ' '  Bull,  et  Mem. 
Soc.  de  Chir.  de  Paris,  Feb.  25,  1913,  No.  7,   293. 


672  ANESTHESIA 

a  case  of  lymphangitis  of  the  arm,  for  example,  the  limb  is  carefully 
washed  with  water  and  soap,  as  if  to  prepare  for  operation.  After  the 
skin  has  been  wiped  dry  the  entire  affected  region  is  wrapped  in 
bandages,  on  which  a  liberal  supply  of  ether  is  poured.  The  part  is 
then  wrapped  in  oiled  silk,  which  is  held  in  place  with  straps,  which  are 
tightened  at  the  two  extremities  of  the  dressing,  so  that  the  ether  can 
only  evaporate  slowly,  and,  to  guard  still  further  against  evaporation, 
the  limb  is  surrounded  with  a  thick  layer  of  non-absorbent  cotton. 

Eesults  Obtained. — The  results  obtained  with  this  treatment  are 
excellent,  according  to  Souligoux,  who  has  been  able  to  obtain  many 
cures  in  cases  of  grave  infections.  Ether  has  been  employed  by  him  in 
this  manner  in  several  hundreds  of  cases,  always  with  commendable  re- 
sults. 

Ether  Irrigation  of  the  Abdomen. — Since  1C91  he  has  introduced 
ether  into  the  peritoneal  cavity  of  guinea-pigs  without  harm.  He  did 
not  venture  to  experiment  in  this  way  upon  man,  however,  until  1912. 
This  was  done  under  the  following  conditions:  In  July  he  was  called 
to  see  a  patient  who  for  eight  days  had  suffered  from  intestinal  obstruc- 
tion, with  entire  arrest  of  feces  and  gas,  and  stercoral  vomiting.  On 
the  sixth  day  a  laparotomy  was  performed  for  making  an  artificial  anus. 
The  iliac  incisions  were  followed  by  the  escape  of  gas  and  fecal  matter 
from  the  abdomen,  showing  the  existence  of  a  perforation  of  the  intes- 
tine, which  required  closure.  Median  laparotomy  was  performed.  The 
abdomen  was  filled  with  fecal  matter  and  gas;  the  bloated  coils  were 
covered  with  false  membranes,  and,  after  a  prolonged  search,  a  perfora- 
tion was  found  on  the  cecum,  the  size  of  a  quarter.  This  was  closed. 
Eegarding  the  patient  as  doomed,  remembering  his  experience  with  ether 
in  1891,  and  being  aware  of  Morestin's  frequent  employment  of  ether 
in  abdominal  operations,  Souligoux  poured  ether  into  the  abdomen,- 
upon  the  coils,  into  the  small  pelvis, — in  other  words,  applying  a  thor- 
ough irrigation  of  the  abdomen  with  ether.  After  careful  wiping  two 
drains  were  placed,  one  toward  the  small  pelvis,  the  other  toward  the 
upper  portion  of  the  abdomen. 

To  the  great  surprise  of  Souligoux,  the  patient  made  a  good  recov- 
ery, and  he  has  since  made  free  use  of  ether,  with  excellent  results,  in  all 
abdominal  interventions  associated  with  pus. 

Marcille,  according  to  Souligoux,  followed  the  same  procedure  in  sur- 
gical cases,  as  a  routine  method.  The  following  is  a  summary  of  his  ob- 
servations. 

Clinic  Cases. —  (1)  Six  patients,  operated  upon,  with  peritoneal 
infection,  through  ruptured  tubal  pregnancies.  In  each  instance  the 
peritoneum  of  the  small  pelvis  and  the  affected  coils  of  intestine  vv^ere 
wiped  off  with  ether-soaked  bandages.     He  obtained  six  cures. 

(2)      Seventeen  patients,  operated  upon,  with  strangulated  hernia. 


THERAPEUTIC   USES    OF   INHALATION   ANESTHETICS     673 

In  each  instance  the  coil  was  washed  with  ether.  All  the  patients  heard 
from  were  cured. 

(3)  Three  patients,  operated  upon,  with  abdominal  wounds  and 
contusions,  (a)  Contusion,  at  9  a.  m.  Operation,  at  10  p.  M.  A  per- 
forated coil,  turbid  fluid  in  peritoneal  cavity,  found.  Copious  ether  irri- 
gation. Drainage.  Cure.  (b)  Knife  wound  of  abdomen,  operated 
upon  in  third  hour.  A  divided  coil,  a  small  perforation  of  another  coil, 
two  wounds  of  mesentery,  found.  Copious  ether  irrigation.  Drainage. 
Cure,  (c)  Case  of  frightful  abdominal  traumatism,  the  individual  be- 
ing practically  cut  in  two,  the  wound  extending  from  Scarpa's  triangle 
on  the  right  side  to  the  left  iliac  fossa.  Kepair  of  the  numerous  vascu- 
lar and  visceral  wounds.  Irrigation  with  ether.  Death  during  the 
night. 

(4)  Three  cases  of  general  peritonitis,  operated  upon.  Ether;  free 
drainage.    Two  cures;  one  death. 

(5)  Infarct  of  entire  large  intestine  and  two  meters  of  small  gut, 
all  contained  in  an  enormous  eventration.    Operation.   Part  of  these  coils 

;were  gangrenous;  stercoral  abscesses  had  formed.  Eesection  of  the  en- 
iire  mass  contained  in  the  eventration,  involving  the  entire  large  intes- 
tine as  far  as  the  iliac  flexure,  and  two  meters  of  the  small  intestine. 
Free  ether  irrigation.  Eeestablishment  of  intestinal  functions;  gas  and 
stools.  Good  pulse  next  morning.  Death  from  syncope  after  thirty-six 
hours. 

(6)  Eupture  of  stomach,  through  ulcer.  General  peritonitis,  with 
large  amount  of  purulent  fluid,  false  membranes  in  intestine  found 
upon  operation.  Suture  of  the  perforation.  Free  ether  irrigation. 
Drainage.    Cure. 

(7)  Compound  fracture  of  forearm  bones.  Badly  soiled  wound. 
Washed  with  ether,  and  sutured  without  drainage.  Healed  by  primary 
union. 

Observations. — It  appears,  from  the  sum-total  of  these  observa- 
tions: (1)  That  irrigation  of  the  peritoneal  cavity  with  ether  is  in  uo 
way  injurious.  In  all  the  cases  where  Souligoux  employed  it  he  noted 
that  the  coils  of  intestine  became  pink,  and  contracted  under  the  action 
of  the  ether;  (2)  that  this  irrigation  seemed  to  have  a  powerful  action 
as  a  disinfectant  of  the  peritoneum. 

In  the  discussion  of  Souligoux's  paper  Cuneo  stated  that  ether  dress- 
ings, according  to  the  technique  of  Souligoux,  had  been  employed  by 
him  in  cases  of  lesion  of  the  extremities,  usually  lesions  of  an  inflamma- 
tory character,  such  as  panaris,  phlegmons,  etc.  Excellent  results  were 
obtained  by  this  method.  On  the  other  hand,  the  idea  of  pouring  ether 
into  the  peritoneum  did  not  appeal  to  him.  The  observations  of  Souli- 
goux did  not  seem  to  him  to  be  demonstrative,  and  the  cures  appeared 
to  be  especially  referable  to  the  timeliness  of  the  intervention.    The  sup- 


674  ANESTHESIA 

pression  of  the  cause  of  complications  was  a  factor  in  the  success.  The 
question  of  drainage  he  regarded  as  secondary  in  itself.  He  had  be- 
come convinced  of  this  by  obtaining  a  considerable  proportion  of  cures 
in  general  peritonitis  of  appendicular  origin,  through  the  simple  abla- 
tion of  the  appendix,  and  closure,  without  drainage.  There  is  nothing, 
in  his  opinion,  to  permit  the  claim  that  in  the  observations  of  Souligoux 
the  cure  was  due  to  the  irrigation  of  the  peritoneum  with  ether. 

Souligoux,  in  replying  to  the  remarks  of  Cuneo,  said  the  latter  had 
not  well  understood  the  observations  described.  He  reiterated  some  of 
the  details  of  the  case  of  obstruction  of  eight  days'  standing.  The  per- 
foration, he  said,  may  be  assumed  to  have  coincided  with  the  severe  pain 
which  was  felt  at  this  time.  There  was  an  inundation  of  fecal  matter 
and  gas  in  the  abdomen.  He  had  had  so  little  confidence  himself  in 
the  recovery  of  the  patient  that  when  he  saw  her  in  the  evening  he  be- 
lieved he  had  made  a  mistake  in  the  room,  and  left  without  speaking  to 
her.  On  learning  of  his  mistake  he  returned,  finding  the  woman  in  fairly 
good  condition.  He  was  unable  to  believe  that  her  recovery  was  en- 
tirely independent  of  the  ether.  He  was  convinced,  from  his  observa- 
tions, that  ether  is  not  only  harmless,  but  may  be  very  useful  in  the 
treatment  of  peritoneal  infections. 


CHAPTER    XIX 

THE   MEDICO-LEGAL  STATUS   OF   THE   ANESTHETIST 

John  W.  H.  Crim 

Introduction  :  Police  Power ;  The  Medical  Profession  Established ; 
Contest  Between  the  Schools  of  Medicine;  The  Status  of  the  Physician. 

The  Physician's  Liability:  Ethical  Liability  of  the  Physician; 
The  Civil  Liability  of  the  Physician ;  Malpractice ;  Liability  of  the  Spe- 
cialist; The  Criminal  Liability  of  the  Physician;  Gross  Ignorance  or 
Negligence ;  Statutory  Liability. 

INTRODUCTION 

An  examination  of  the  vast  number  of  decisions  of  the  higher  courts 
of  the  several  States  of  the  United  States  discloses  the  fact  that  the 
discovery  and  use  of  anesthetics  ^  by  the  medical  profession  have  had 
little  or  no  effect  upon  the  well-established  principles  of  medical  juris- 
prudence, and  the  profession  of  the  anesthetist,  of  inestimable  im- 
portance to  the  medical  profession,  and  consequently  to  society  in  gen- 
eral, has  found  no  place  either  in  our  courts  or  legislatures.  At  the 
outset  it  may  be  said  that  only  those  having  qualifications  of  a  physi- 
cian ^  or  dentist  should  be  permitted  to  administer  anesthetics ;  that 
it  should  be  made  a  penal  offense  in  every  State  for  any  person  other 
than  a  legally  qualified  medical  or  dental  practitioner  to  administer 
either  a  general  or  local  anesthetic  or  a  drug  for  the  purpose  of  produc- 

*  That  which  produces  insensibility  to  pain:     State  v.  Baldwin,  36  Kan.,  1. 

^  The  term  "physician"  is  here  used  in  a  broad  sense,  inchiding  all  who  are 
lawfully  engaged  in  the  practice  of  medicine :     Harrison  v.  State,  102  Ala.,  170. 

At  one  time  the  term  "physician"  was  employed  in  contradistinction  to  that 
of  ' '  surgeon, ' '  but  the  modern  use  of  the  term  includes  those  who  perform  surgery 
as  well:  Alison  v.  Eaydon,  4  Bing.,  619;  Wetlierel  v.  Marion  County,  28  Iowa, 
22;  Little  v.  SMer,  33  N.  J.  L.,  507;  Matter  of  Hxmter,  €0  N.  C,  447. 

The  term  "Physician  and  Surgeon"  is  not  limited  to  any  one  school  of  prac- 
titioners:    Eaynor  v.  State,  62  Wis.,  289. 

Osteopaths  hardly  come  within  this  classification,  unless  they  have  pursued  suc- 
cessfully an  accepted  course  of  study  in  medicine.  For  statutory  definitions  of 
above  terms,  see  Public  Health  Law  New  York,  1909. 

675 


676  ANESTHESIA 

ing  a  state  of  unconsciousness  during  any  medical,  surgical,  or  dental 
operation.  Dentists  should  be  permitted  to  administer  such  anesthetics, 
general  and  local,  as  are  necessary  in  the  practice  of  dental  or  oral 
surgery  and  medicine,  and  should  not  be  permitted  to  give  either  a  local 
or  general  anesthetic  in  other  medical  or  surgical  operations  or  during 
childbirth.  To  determine  the  fundamental  responsibility  of  an  anes- 
thetist, one  must  look  to  the  general  principles  of  law  which  apply 
to  the  physician  in  the  ordinary  practice  of  his  profession,  with  this  ex- 
ception: the  practitioner  holding  himself  out  to  the  public  as  an  anes- 
thetist is  properly  considered  a  specialist,  and  is  therefore  held  to  a 
commensurately  higher  degree  of  skill  and  learning,  in  so  far  as  the 
administration  of  anesthetics  is  concerned,  than  the  ordinary  practi- 
tioner.^ It  will  therefore  suffice,  for  the  purposes  of  this  chapter,  to 
indicate  the  general  principles  which  define  the  duties  of  the  physician 
with  regard  to  his  ethical,  civil,  and  criminal  responsibility,  and  to  dis- 

^  In  this  place  it  is  appropriate  to  insert  a  summary  of  views  relative  to  the 
training  and  status  of  the  anesthetist. 

Hellman  (N.  ¥.  Med.  J.,  95,  No.  22,  1146)  considers  that  no  one  without  a 
medical  training  can  ever  become  an  expert  anesthetist,  and  that  nurses,  sisters 
of  mercy,  and  others  should  be  excluded  from  general  anesthetic  work.  The  ad- 
ministration of  anesthetics  is  legally  medical  practice,  and  as  such  may  be  han- 
dled only  by  graduate  physicians  in  New  York. 

However,  we  may  point  out  that  instruction  in  the  practical  administration  of 
anesthetics  should  be  a  requisite  part  of  the  regular  medical  and  dental  courses. 
On  the  training  required  by  the  anesthetist,  see  the  discussion  in  J.  Am.  Med.  Assn., 
5S,  No.  20,  1614-5;  and  on  the  teaching  of  anesthetics,  see  an  earlier  paper, 
ibid.,  51,  No.  14,  1167. 

Chipman  {Va.  Med.  Senii-Mon.,  15,  No.  12,  278)  discusses  the  general  signifi- 
cance of  the  term  ' '  anesthetist. ' '  In  the  * '  paid  anesthetist  system, ' '  the  anes- 
thetist gives  all  anesthetics,  in  private- cases  receiving  remuneration  from  the  pa- 
tient, directly  or  indirectly,  while  with  ward  cases  he  either  administers  himself 
or  has  an  interne  give  the  anesthetic  under  his  direction,  and  for  these  cases  he 
receives  no  compensation.  This  system,  Chipman  maintains,  is  a  long-delayed 
need.  He  considers  that  the  trained  anesthetist  should  play  a  very  large  part  in 
reducing  the  death  rate  to  a  minimum. 

"The  Trained  Anesthetist"  has  been  discussed  by  Porter.  {Lancet-Clinic, 
103,  No.  25,  641.)  He  thinks  that  the  administration  of  anesthetics  should  only 
be  done  by  the  trained  man  and  that  he  should  be  an  expert.  He  goes  on  to  say: 
"Surgeons  should  insist  upon  having  a  trained  anesthetist  for  all  operations. 
.     .     .     The  anesthetist 's  work  is  the  equal  of  any  other  special  line  of  work. ' ' 

Abernethy  {Southern  Med.  J.,  3,  No.  8,  489)  has  treated  of  the  anesthetist 
as  a  specialist.  In  the  administration  of  a  general  anesthetic  the  exercise  of 
judgment  and  skill  is  necessary,  and  this  can  only  be  obtained  through  special  study 
and  experience.  As  much  care  should  be  exercised  in  the  administration  as  in  the 
performance  of  an  operation;  and  the  anesthetist  should  have,  and  does  have  in 
properly  regulated  cases,  as  much  responsibility  as  the  surgeon. 

On  the  general  practitioner  as  an  anesthetist,  see  Moriarta:  J.  Am.  Med. 
Assn.,  53,  No.  10,  768;  and,  on  the  professional  anesthetist,  consult  Metzenbaum: 
Ohio  State  Med.  J.,  6,  No.  3,  124. 


THE   MEDICO-LEGAL   STATUS    OF   THE   ANESTHETIST     677 

cuss,  in  appropriate  places,  the  legislation  and  decisions  pertaining  to 
the  administration  of  anesthetics  by  physicians,  surgeons,  anesthetists, 
and  dentists. 

Police  Power. — The  application  of  the  principles  of  law  to  the 
relations  between  physician  and  patient  has  its  source  in  the  right  of 
society  to  prescribe  rules  of  human  conduct  which  conduce  to  the  gen- 
eral welfare,  that  is,  the  police  power  inherent  in  sovereignty;  accord- 
ingly, it  is  to  the  police  power  of  a  State  ^  that  society  looks  for  protec- 
tion from  ignorance,  superstititon,  and  quackery  in  the  medical  profes- 
sion. The  limitation  upon  legislatures  in  enacting  statutes  for  the  pur- 
pose of  regulating  the  practice  of  medicine  is  measured  by  the  extent  of 
the  police  power;  and,  conceding  that  the  protection  of  public  health  is 
of  vital  importance  in  modern  government,  a  most  casual  examination 
of  the  early  legislation,  or  the  want  thereof,  reveals  the  inadequacy,  as  it 
were,  of  the  ancient  forms  of  government  in  this  respect.  For  example, 
we  are  told  that,  under  the  Eoman  civil  law  and  the  English  common 
law,  the  right  to  practice  medicine  and  surgery  was  free  to  all  persons.- 
It  is  therefore  not  surprising  to  learn  that  the  barber  ^  and  the  priest  * 
were  relied  upon  to  "heal  the  ill.^'  Speculation  upon  the  inadequacy 
of  a  government  which  permitted  such  a  condition  receives  additional 
interest  in  the  fact  that  the  barber  and  priest  could  not  sue  and  recover 
for  their  services — a  cardinal  privilege  of  the  twentieth  century  practi- 
tioner, not  only  from  the  standpoint  of  sustenance,  but  because  a  judg- 
ment in  his  favor  for  services  rendered  is  an  estoppel  to  a  civil  action 
against  him  for  malpractice;  conversely,  proof  of  malpractice  is  a  de- 
fense to  an  action  for  professional  services.^  Custom  precluded  the  prac- 
titioner from  making  a  specific  charge  for  his  services,  and  required  him 
to  accept  whatever  compensation,  or  Jionorarium,  as  it  was  then  called, 
his  patient  chose  to  pay.  The  inevitable  result  of  the  conditions  fostered 
by  these  customs  prompted  Parliament  to  pass  a  statute  during  the  reign 
of  Henry  V.  (1422),  which,  under  a  penalty  of  both  line  and  imprison- 
ment, prohibited  anyone  "using  the  mysterie  of  physyck  unless  he  hath 
studied  in  some  university  and  is  at  least  a  bachelor  of  science." 

The  Medical  Profession  Established. — Following  this  legislation  by 

^See  Com.  v.  Gibson,  7  Pa.  Dist.  Eep.,  386;  Com.  v.  Finn,  11  Pa.  Sup.  Ct.,  620; 
Matter  of  Campbell's  Registration,  197  Pa.,  581;  Dent  v.  W.  Va.,  129  U.  S.,  114; 
Eeetz  V.  Mich.,  188  U.  S.,  505. 

''Benton  v.  State,  21  Neb.,  445;  State  v.  Morrill,  7  Ohio  Dec,  52;  State  v. 
Carey,  4  Wash.,  424. 

^Allison  V.  Haydon,  4  Bing.,  619.  On  the  low  state  of  surgery  in  the  Middle 
Ages,  see  Kottelmann:     "  Gesundheitspflege  in  Mittelalter, "  1890,  216. 

*  Baas :  ' '  Geschichte  der  Medicin, ' '  204 ;  von  Raumer :  ' '  Hohenstauf  en, ' '  6, 
438;  Fort:  "History  of  Medical  Economy  During  the  IVIiddle  Ages,"  1883, 
chaps,  xiii  and  xviii. 

^Abbott  V.  Mayfield,  8  K^n.  App.,  387. 


678  ANESTHESIA 

Parliament,  the  practice  of  medicine  savored  of  a  profession;  but  it  was 
not  until  Parliament  enacted  the  well-known  act  of  Henry  VIII. / 
which  denounced  the  medical  profession  as  "ignorant  persons  who  could 
tell  no  letters  on  the  book,  common  artificers,  smiths,  weavers,  and 
women,  who  took  upon  themselves  great  cures,  partly  using  sorcery  and 
witchcraft,  and  partly  applying  very  noxious  medicines  to  the  disease," 
that  it  became  a  well-defined  and  established  profession.  With  this  cloak 
of  legislative  protection  thrown  around  it,  the  profession  at  once  at- 
tained a  higher  standard;  medical  schools  were  organized  and  various 
systems  of  medicine  came  into  existence. 

Contest  Between  the  Schools  of  Medicine. — The  greater  amount  of 
subsequent  legislation  in  both  England  and  America,  between  1550  and 
1890,  grew  out  of  the  jealousy  existing  between  the  followers  of  such 
schools  as  Allopathy  and  Homeopathy.  It  is  indeed  a  curious  com- 
mentary on  the  history  of  the  medical  profession  that  the  enmity  be- 
tween the  several  schools  and  systems,  growing  out  of  the  efllorts  of  one 
to  fortify  itself  by  legislation  at  the  expense  of  loss  of  privilege  to  the 
other,  was  reflected  in  the  legislature  of  the  State  of  New  York  during 
the  latter  half  of  the  nineteenth  century,  when,  in  its  efforts  to  appease 
the  warring  schools,  it  enacted  laws  so  liberal  that  the  doors  of  the  medi- 
cal profession  were  opened  to  ignorant,  and  even  fraudulent,  empirics — 
a  condition  which  happily  has  been  remedied  by  more  recent  legisla- 
tion. 

The  Status  of  the  Physician. — The  legal  status  of  a  physician  is 
frequently  compared  to  that  of  the  lawyer,  but  there  is  one  important 
element  which  differentiates  the  two  professions  and  should  be  con- 
stantly borne  in  mind  in  any  comparison;  the  lawyer  is  an  officer  of 
the  Court,  and,  because  of  this  relation,  the  Court  has  summary  power 
to  inquire  into  his  professional  conduct  in  connection  with  any  case; 
whereas  the  physician  is  under  no  such  restraint,  and  the  medical  so- 
cieties, which  have  been  organized  for  the  purpose  of  protecting  the 
public  against  imposters,  frequently  find  this  power  so  limited  that  it 
often  becomes  necessary  for  the  public  to  resort  to  the  legislature  for 
protection.  The  status  of  a  physician  in  this  country  was  ably  de- 
scribed by  the  late  Justice  Pield,  in  delivering  the  opinion  of  the  Su- 
preme Court  of  the  United  States  affirming  the  constitutionality  of 
the  legislation  prescribing  the  qualifications  of  one  to  practice  medi- 
cine:^ "Few  professions  require  more  careful  preparation  by  one  who 
seeks  to  enter  it  than  that  of  medicine.  It  has  to  deal  with  all  those 
subtle  and  mysterious  influences  upon  which  health  and  life  depend, 
and  requires  not  only  a  knowledge  of  the  properties  of  vegetable  and 

''3  Henry  VIII.,  c.   11;   14  and  15  Henry  VIII.  5;    5  Car.,  1. 
"Bent  V.  West  Virginia,  129  U.  S.,  114,  affirming  25  W.  Va.,  1.     For  the  med- 
ical practice  laws  of  all  States,  see  "American  Medical  Directory,"  3rd  ed.,  1912. 


THE  MEDICO-LEGAL   STATUS    OF   THE   ANESTHETIST     679 

mineral  substances,  but  of  the  human  body  in  all  its  complicated  parts, 
and  their  relation  to  each  other,  as  well  as  their  influence  upon  the 
mind.  The  physician  must  be  able  to  detect  readily  the  presence  of 
disease,  and  prescribe  appropriate  remedies  for  its  recovery.  Everyone 
may  have  occasion  to  consult  him,  but  comparatively  few  can  judge  of 
the  qualifications  of  learning  and  skill  which  he  possesses.  Keliance 
must  be  placed  upon  the  assurance  given  by  his  license,  issued  by  an 
authority  competent  to  judge  in  that  respect,  that  he  possesses  the 
requisite  qualifications.  Due  consideration,  therefore,  for  the  protec- 
tion of  society  may  well  induce  the  State  to  exclude  from  practice  those 
who  have  not  such  a  license  or  who  are  found  upon  examination  not  to 
be  fully  qualified.  The  same  reasons  which  control  in  imposing  con- 
ditions, upon  compliance  with,  which  the  physician  is  allowed  to  prac- 
tice in  the  first  instance,  may  call  for  further  conditions  as  new  modes 
of  treating  disease  are  discovered,  or  more  thorough  acquaintance  is 
obtained  of  the  remedial  properties  of  vegetable  and  mineral  substances, 
or  a  more  accurate  knowledge  is  acquired  of  the  human  system  and  of 
the  agencies  by  which  it  is  affected.  It  would  not  be  deemed  a  matter 
for  serious  discussion  that  a  knowledge  of  the  new  acquisitions  of  the 
profession,  as  it,  from  time  to  time,  advances  in  its  attainments  for  the 
relief  of  the  sick  and  suffering,  should  be  required  for  continuance  in 
its  practice,  but  for  the  earnestness  with  which  the  plaintiff  in  error 
insists  that,  by  being  compelled  to  obtain  the  certificate  required,  and 
prevented  from  continuing  in  his  practice  without  it,  he  is  deprived  of 
his  right  and  estate  in  his  profession  without  due  process  of  law.  We 
perceive  nothing  in  the  statute  which  indicates  an  intention  of  the 
legislature  to  deprive  one  of  any  of  his  rights/' 

The  wisdom  underlying  the  statutes  requiring  a  general  education 
as  a  prerequisite,  supplemented  by  special  study  at  accredited  medical 
schools,  as  qualifications  precedent  to  the  application  for  the  license  to 
practice  medicine,  cannot  be  questioned.  The  legislation  of  the  sev- 
eral States  of  the  United  States  in  this  respect  has  been  approved  by 
the  courts  in  holding  those  statutes  constitutional  which  prohibit  the 
practice  of  medicine  and  surgery  by  unlicensed  persons.^  On  the  other 
hand,  when  the  licentiate  has  conformed  to  these  reasonable  require- 
ments, it  follows  that  it  is  the  better  part  of  wisdom  to  rely  on  his 
integrity  ~  and  desire  to  succeed  in  the  application  of  his  knowledge, 
skill,  and  judgment,  thereby  characterizing  his  profession  Avith  little 
restraint  in  the  fields  of  experiment  and  investigation;  for  to  limit  the 

^BlalocJc  V.  State,  112  Ga.,  338;  0 'Conner  v.  State,  46  Neb.,  157;  State  v. 
Mylod,  20  E.  I.,  632;  State  v.  Van  Doran,  109  N.  C,  864;  Hale  v.  State,  5S  Ohio 
St.,  676;  State  v.  Carey,  4  Wash.,  424. 

^  That  a  State  may  require  good  character  on  the  part  of  the  licentiate : 
Hawker  v.  Netv  York,  170  U.  S.,  189. 


680  ANESTHESIA 

latitude,  os  it  were,  of  his  independence  of  thought,  obviously  would 
be  tantamount  to  impeding  progress  in  both  the  art  and  science  of 
medicine.  By  the  same  token,  it  is  impossible  to  prescribe  a  fixed  rule 
of  responsibility  on  the  part  of  the  practitioner,  inasmuch  as  the  cir- 
cumstances and  conditions  surrounding  cases  vary,  and  accordingly  all 
conclusions  with  respect  to  a  physician's  liability  must  be  drawn  from 
the  facts  underlying  each  particular  case.  It  is  upon  this  theory  that 
the  courts  have  held  that  the  defendant  cannot  successfully  meet  the 
charge  of  malpractice  by  showing  his  methods  were  successful  in  simi- 
lar cases.^ 

THE  PHYSICIAN'S  LIABILITY 

Ethical  Liability  of  the  Physician. — While  the  privilege  which 
permits  the  lips  of  the  physician  to  remain  sealed  and  to  hold  inviolate 
the  relations  between  physician  and  patient  has  its  foundation  in  the 
civil  resi^onsibility  of  the  physician  to  inform  himself  of  the  habits, 
tendencies,  circumstances,  and  history  of  the  patient,^  it  is  to  that  higher 
law,  the  ethics  of  the  medical  profession,  that  society  must  ultimately 

^  Baker  v.  Hancock,  63  N.  E.,  323;  64  N.  E.,  38;  but  see  Stern  v.  Laning,  106 
La.,  738. 

^  Communications  from  a  patient  to  his  physician  were  not  privileged  at  com- 
mon law:  Eex  v.  Gibbons,  L.  C.  and  P.,  97;  Broad  v.  Pitt,  3  C.  and  P.,  518;  God- 
dard  v.  Gardner,  28  Conn.,  172;  Barnes  v.  Harris,  7  Cush.  Mass.,  577;  People  v. 
Stout,  3  Park.  Crim.  N.  Y.,  670 ;  Kendall  v.  Grey,  2  Hilt.  N.  Y.,  300 ;  but  on  con- 
siderations of  public  policy:  Lissak  v.  Crocker,  119  Cal.,  442;  Kling  v.  Kansas 
City,  27  Mo.  App.,  231;  Boyt  v.  Hoyt,  112  N.  Y.,  493. 

Statutes  have  been  enacted  in  most  jurisdictions  prohibiting  the  disclosure, 
against  the  will  of  the  patient,  of  information  acquired  by  physicians  in  their 
professional  capacity:  Conn.  Mut.  L.  Ins.  Co.  v.  Union  Trust  Co.,  112  U.  S.,  250; 
Dreier  v.  Cont.  L.  Ins.  Co.,  24  Fed.  Eep.,  670;  Shafer  v.  Eau  Claire,  105  Wis., 
239.;  Wells  v.  N.  E.  Mut.  L.  Ins.  Co.,  187  Pa  St.,  166;  Davis  v.  Swpreme  Lodge, 
etc.,  165  N.  Y.,  159;  Territory  v.  Corbett,  3  Mont.,  50;  Blair  v.  Chicago,  etc., 
89  Mo.,  334,  383 ;  Cooley  v.  Foltz,  85  Mich.,  47 ;  Nelson  v.  Niederland  Co.,  110  Iowa, 
600;  Bower  v.  Bower,  142  Ind.,  194;  and  Colo.  Fuel  Co.  v.  Cummings,  8  Colo. 
App.,  541.  In  the  case  of  Robinson  v.  Swpreme  Commandery,  U.  C.  G.  C.  of  W., 
79  N.  Y.  S.,  13,  it  was  stated  that  Code  Civ.  Proc.,  834,  provides  that  physicians 
shall  not  be  allowed  to  disclose  information  acquired  in  attending  a  patient  in  a 
professional  capacity.  An  Indiana  statute  provides  that  a  physician  shall  be 
incompetent  to  testify,  over  his  patient's  objections,  as  to  any  knowledge  acquired 
by  him  in  treating  such  patient:  Aspy  v.  Botkin,  66  N.  E.,  462.  Utah  Eev.  St., 
3414,  provides  that  a  physician  cannot,  without  the  consent  of  his  patient,  be  ex- 
amined in  a  civil  action  as  to  any  information  acquired  in  attending  the  patient 
which  was  necessary  to  enable  him  to  prescribe  for  the  patient.  In  order  that 
such  statutes  may  apply,  it  is  necessary  that  the  relation  of  physician  and  patient 
should  exist  or  at  least  that  conditions  are  such  that  the  patient  is  impressed 
with  the  belief  that  it  does:  People  v.  Koerner,  154  N.  Y.,  355;  Clarke  v.  State, 
8  Kan.  App.,  782. 


THE  MEDICO-LEGAL   STATUS    OF   THE   ANESTHETIST     681 

look  for  protection  rather  than  to  legislatures  and  courts.  The  sanc- 
tity of  the  relations  between  physician  and  patient  has  ever  been  held 
with  a  most  profound  appreciation  throughout  the  history  of  the  medi- 
cal profession;  and  in  this  respect  the  comprehensive  ethical  code  at- 
tributed to  Hippocrates  admits  of  no  amendment. 

The  Civil  Liability  of  the  Physician. — In  defining  the  necessary 
qualifications  on  the  part  of  the  practitioner,  the  courts  have  held,  with- 
out exception,  that  one  holding  himself  out  to  the  public  as  a  general 
practitioner  of  medicine  and  surgery  must  possess  and  exercise  the 
average  degree  of  skill  and  learning  possessed  by  members  of  the  pro- 
fession practicing  in  similar  localities,^  in  the  light  of  the  present  state 
of  medical  science.^  The  physician  is  not  infallible,  and,  except  by  ex- 
press agreement,  in  accepting  a  case,  does  not  guarantee  a  cure.^  The 
reasonable  and  ordinary  care,  skill,  and  diligence  demanded  by  this  rule, 
are  those  which  are  commonly  practiced  by  physicians  and  surgeons  in 
the  same,  or  similar,  localities  and  in  the  same  general  line  of  practice  in 
similar  cases.  The  degree  of  care,  skill,  and  diligence  varies  in  differ- 
ent communities  ^  and  in  different  cases.  The  opportunity  for  observ- 
ing the  latest  approved  methods  of  treatment,  and  the  facilities  for 
obtaining  drugs  and  appliances,  are  material  in  determining  the  re- 
sponsibility on  the  part  of  the  practitioner;  hence,  it  will  be  seen  that 
the  above  rule  exacts  higher  degrees  of  care,  skill,  and  diligence  on  the 
part  of  the  city  practitioner,  than  is  demanded  of  the  practitioner  in 
the  more  remote  communities. 

"^  Pike  V.  Honsinger,  155  N.  Y.,  201;  Eislein  v.  Palmer,  7  Ohio  Dec,  365; 
Lawson  v.  Comnaway,  37  W.  Va.,  159;  Nelson  v.  Harrington,  72  Wis.,  591;  Mullin 
V.  Flanders,  73  Vt.,  95;  Jackson  v.  Burnham,  20  Colo.,  532;  and  Force  v.  Gregory, 
63  Conn.,  167. 

Not  in  "his  locality":  Whitesell  v.  Hill,  101  Iowa,  629;  Burk  v.  Foster,  24 
Ky.  Law  Rep.,  791;  114  Ky.,  20.  Cf.  53  Neb.,  28;  92  N.  Y.  S.,  1063;  and  37 
W.  Va.,  159,  wherein  "his  community"  is  specified.  In  Wohlert  v.  Seihert,  23  Pa. 
Super.  Ct.,  213,  the  comparative  distinction  is  "the  skill  .  .  .  ordinarily  pos- 
sessed by  the  average  of  members  of  the  profession  in  good  standing. ' ' 

"  Baker  v.  Hancock,  63  N.  E.,  323 ;  29  Ind.  App.,  456 ;  64  N.  E.,  38 ;  Thomas 
V.  Dabblemont,  67  N.  E.,  463;  31  Ind.  App.,  146;  Dunbauld  v.  Thompson,  80 
N.  W.,  324;  109  Iowa,  199;  Forrell  v.  Ellis,  105  N.  W.,  993;  129  Iowa,  614;  Gil- 
lette V.  Tucker,  65  N.  E.,  865;  67  Ohio  St.,  106;  93  Am.  St.  Eep.,  639;  Bigney  v. 
Fischer,  59  A.,  72;  26  E.  I.,  402;  and  Eislein  v.  Palmer,  7  Ohio,  Dec,  365.  On 
the  implied  undertaking  of  a  physician,  see  also  Eich  v.  Pierpont,  3  F.  and  P.,  35; 
Pettigrew  v.  Lewis,  46  Kan.,  78;  Small  v.  Howard,  128  Mass.,  131;  Pike  v.  Hon- 
singer, 155  N.  Y.,  203;  McCandless  v.  McWha,  22  Pa.  St.,  261.  In  the  last  case 
it  was  stated  that  the  care,  skill,  and  diligence  exercised  must  be  that  of  "thor- 
oughly educated"  physicians,  but  it  was  evidently  not  intended  to  impose  a 
higher  standard  of  care  than  that  usually  required.  See  Smothers  v.  Hanks,  34 
Iowa,  286. 

'  Ewing  v.  Goode,  78  P.,  442 ;  Dye  v.  Corbin,  59  W.  Va.,  266. 

*  Whitesell  v.  Hill,  70  N.  W.,  750. 


682  ANESTHESIA 

Malpractice. — The  failure  on  the  part  of  the  practitioner  to  exer- 
cise "the  average  degree  of  skill  and  learning  possessed  by  members  of 
the  profession  practicing  in  similar  localities,  in  the  light  of  the  present 
state  of  medical  science,"  resulting  in  injury  to  the  patient,  is  malprac- 
tice, and  renders  the  practitioner  liable  for  the  injuries  resulting  there- 
from.^ However,  a  mere  error  in  judgment  does  not  constitute  mal- 
practice, unless  such  error  is  inconsistent  with  the  degree  of  skill  which 
it  is  the  duty  of  a  physician  to  possess.  In  a  leading  case  the  Court 
has  said :  ^  "The  law  relating  to  malpractice  is  simple  and  well  settled, 
although  not  always  easy  of  application.  A  physician  and  surgeon,  by 
taking  charge  of  a  case,  impliedly  represents  that  he  possesses,  and  the 
law  places  upon  him  the  duty  of  possessing,  that  reasonable  degree  of 
learning  and  skill  that  is  ordinarily  possessed  by  physicians  and  sur- 
geons in  the  same  or  similar  locality  where  he  practices,  and  which  is 
ordinarily  regarded  by  those  conversant  with  the  employment  as  necessary 
to  qualify  him  to  engage  in  the  business  of  practicing  medicine  and 
surgery.  Upon  consenting  to  treat  a  patient,  it  becomes  his  duty  to  use 
reasonable  care  and  diligence  in  the  exercise  of  his  skill  and  the  applica- 
tion of  his  learning  to  accomplish  the  purpose  for  which  he  was  employed. 
He  is  under  the  further  obligation  to  use  his  best  judgment  in  exercising 
his  skill  and  applying  his  knowledge.  The  law  holds  him  liable  for  an  in- 
jury to  his  patient  resulting  from  want  of  the  requisite  knowledge  and 
skill,  or  the  omission  to  exercise  reasonable  care,  or  the  failure  to  use  his 
best  judgment.  The  rule  in  relation  to  learning  and  skill  does  not  require 
the  surgeon  to  possess  that  extraordinary  learning  and  skill  which  be- 
long only  to  few  men  of  rare  endowments,  but  such  as  are  possessed 
by  the  average  number  of  the  medical  profession  in  good  standing. 
Still  he  is  bound  to  keep  abreast  with  the  times,  and  a  departure  from 
approved  methods  in  general  use,  if  it  injures  the  patient,  will  render 
him  liable,  however  good  his  intentions  may  have  been." 

The  failure  on  the  part  of  the  patient  to  follow  the  reasonable  and 
necessary  instructions  of  the  physician  relieves  him  of  responsibility.^ 
Similarly,  a  physician  is  under  no  legal  obligation  to  accept  a  case 
against  his  will;  but,  having  accepted,   he  cannot   withdraw  without 

^  But  a  mere  want  of  due  care  and  skill  gives  no  right  of  action  when  no  injury 
has  resulted :  Swing  v.  Goode,  78  Fed.  Rep.,  442 ;  Cay  ford  v.  Wilbur,  86  Me.,  414 ; 
Bowe  V.  Lent,  42  N.  Y.,  483 ;  Fowler  v.  Sergeant,  1  Gant.  Cas.  Pa.,  355. 

^ Pike  V.  Eonsinger,  155  N.  Y.,  201.  On  a  physician's  liability  for  errors  of 
judgment,  see  also  Carpenter  v.  BlaTcer,  50  N.  Y.,  696;  Heath  v.  Glisan,  3  Or.,  64; 
McEee  v.  Allen,  94  111.,  App.,  147.  As  to  what  constitutes  negligence  or  malprac- 
tice, see  Sullivan  v.  McGraw,  118  Mich.,  39;  Keller  v.  Lewis,  65  Ark.,  578. 

^  Geiselman  v.  Scott,  25  Ohio  St.,  86 ;  Becker  v.  Janinski,  27  Abb.  Cas.  N.  Y., 
45;  Haire  v.  Eeese,  7  Phila.,  138;  Haering  v.  Spicer,  92  111.  App.,  449;  DuBois  v. 
Decker,  130  N.  Y.,  325.  For  contributory  negligence  on  the  part  of  patient: 
Haering  v.  Spicer,  92  111.  App.,  449. 


THE  MEDICO-LEGAL   STATUS    OF   THE   ANESTHETIST     083 

giving  reasonable  notice/  and  the  fact  that  his  services  are  gratuitous 
does  not  relieve  him  of  the  responsibility  to  exercise  reasonable  and 
ordinary  care,  skill,  and  diligence.  He  is  civilly  responsible  for  the 
want  of  skill  and  negligence  on  the  part  of  his  partners,  agents,  ap- 
prentices, and  assistants/  and,  while  he  incurs  no  liability  in  the  failure 
to  effect  a  cure,^  in  case  he  doubts  his  competency  in  a  particular  case 
it  is  both  his  legal  and  moral  duty  to  recommend  the  employment  of 
another  physician.*  The  physician  is  under  an  implied  obligation, 
when  he  undertakes  a  case,  to  bring  to  his  assistance  such  obtainable 
remedies  and  appliances  as  discovery  and  experience  have  found  to  be 
most  proper  and  beneficial,  and  which  are  therefore  sanctioned  by  use 
in  such  cases ;  ^  but  the  mere  fact  that  the  instrument  used  is  unusual 
is  not  sufficient  to  show  a  want  of  care  and  skill. ^  The  practitioner  is 
chargeable  with  a  knowledge  of  the  probable  consequences  of  an  injury 
or  of  negligence  or  unskilfulness  /  he  is  bound  also  to  know  the  natural 
and  probable  results  of  the  remedy  he  uses ;  ^  and,  in  order  to  be  relieved 
from  liability  on  the  ground  that  his  course  was  pursued  through  an 
error  of  judgment,  he  must  keep  within  recognized  and  approved  meth- 
ods, and  cannot  depart  from  the  known  rule  and  usage  of  the  profes- 
sion to  ramble  in  the  fields  of  investigation  and  experiment."  Finally, 
it  should  not  be  overlooked  that  it  is  the  duty  of  the  physician  to  in- 
form himself  of  those  habits,  tendencies,  and  circumstances  of  the  pa- 

^  On  the  liability  of  a  physician  for  failure  to  attend  a  patient,  see  Dale  v. 
Lumber  Co.,  48  Ark.,  188;  Mucci  v.  Houghton,  89  Iowa,  608;  Barbour  v.  Martin, 
62  Me.,  536;  Gerlcen  v.  Plimpton,  70  N.  Y.  S.,  793;  62  App.  Div.,  35;  Lathrope 
V.  Flood,  63  Pac,  1007. 

On  the  physician's  right  to  determine  the  frequency  of  his  visits  to  a  patient, 
see  51  L.  E.  A.,  298. 

^  Tish  V.  Welker,  5  Ohio  Dec,  725;  Willcins  v.  Ferrell,  10  Texas  Giv.  App.,  231. 

^Physicians  are  not  insurers  of  successful  or  beneficial  results:  Swing  v. 
Goode,  78  Fed.  Eep.,  442;  Styles  v.  Tyler,  64  Conn.,  432;  Tish  v.  Welker,  7 
Ohio  N.  P.,  472;  McKee  v.  Allen,  94  111.  App.,  147;  English  v.  Free,  205  Pa.,  624. 

*See  Mallen  v.  Boynton,  132  Mass.,  443. 

^Stevenson  v.  Gelsthorpe,  10  Mont.,  563;  McCandless  v.  McWha,  22  Pa.,  261. 

'Alder  v.  Buckley,  1  Swan  Tenn,,  69;  Prichard  v.  Moore,  75  111.  App.,  553. 

It  has  been  ruled  in  Missouri  (Vanhooser  v.  BergTioof,  90  Mo.,  487)  that 
whether  or  not  the  practitioner  in  substituting  other  appliances  for  those  which  had 
been  properly  tested  and  were  commonly  used  was  guilty  of  a  want  of  the 
requisite  degree  of  care  and  skill  is  a  question  for  the  jury.  This  decision  is  of 
particular  interest  to  the  anesthetist,  since  the  development  of  anesthetic  apparatus 
is  progressive,  and  the  introduction  of  novel  appliances  is  largely  due  to  indi- 
vidual effort  and  experience. 

'  Gerken  v.  Plimpton,  62  N.  Y.  App.  Div.,  35;  Dubois  v.  Decker,  130  N.  Y.,  325. 

^  Bogle  V.  Winslow,  5  Phila.,  136;   20  Leg.  Int.,  46. 

» Slater  v.  Baker,  2  Wils.  C.  PL,  359 ;  Jackson  v.  Burnham,  20  Colo.,  532 ;  Teffi 
V.  Wilcox,  6  Kan.,  46;  Branner  v.  Stormont,  9  Kan.,  51;  Patten  v.  Wiggin,  51 
Me.,  594;  Hesse  v.  Knippel,  1  Mich.  N.  P.,  109;  Pike  v.  Honsinger,  155  N.  Y.,  203. 


684  ANESTHESIA 

tient  which  are  necessary  and  relevant  in  the  prudent  management  of 
the  case. 

Liability  of  the  Specialist. — If  the  specialist  professes  to  belong  to 
a  particular  school  of  practitioners/  he  must  measure  up  to  the  stand- 
ard of  that  school/  for  "the  law  implies  that  surgeons  and  physicians, 
in  the  treatment  of  all  cases  they  undertake,  should  exercise  reasonable 
care  and  diligence,  and  should  give  attention  proportionate  to  the  deli- 
cacy of  the  operation  and  case." 

It  is  upon  this  theory  that  if  a  physician  holds  himself  out  as  hav- 
ing special  knowledge  and  skill,  "he  is  bound  to  bring  to  the  discharge 
of  his  duty  to  a  patient  employing  him  as  such  specialist  not  merely 
the  average  degree  of  skill  possessed  by  general  practitioners,  but  that 
special  degree  of  skill  and  knowledge  possessed  by  physicians  who  are 
specialists  in  such  cases,  in  the  light  of  the  present  state  of  scientific 
knowledge,^  for,  obviously,  to  measure  the  liability  of  a  specialist  by 
the  standard  appliable  to  the  ordinary  family  physician,  would  open 
the  door  of  the  medical  profession  to  quackery  and  permit  consequent 
fraud  upon  the  public. 

In  defining  the  responsibilities  of  a  specialist,  a  Court*  has  well 
said:  "The  question  when  a  physician  becomes  a  specialist  is  not  one 
of  law,  but  one  of  fact  primarily  for  his  own  determination;  but,  when 
he  holds  himself  out  as  a  specialist,  it  becomes  his  duty  to  use  that  de- 
gree of  skill  which  such  a  practitioner  of  necessity  should  possess." 

The  reasoning  in  this  opinion  is  not  predicated  upon  any  new 
theory,  nor  in  its  application  is  it  peculiar  to  the  relations  between 
physician  and  patient,  for  it  is  a  well-established  principle  of  law  that, 
"in  all  those  employments  where  peculiar  skill  is  requisite,  the  one  who 
offers  his  services  is  understood  as  holding  himself  out  to  the  public  as 
possessing  the  degree  of  skill  commonly  possessed  by  others  in  the  same 
employment." 

With  respect  to  the  degree  of  skill  required  by  anesthetists,  the  de- 
cisions pertaining  to  specialists^  fortify  the  conclusion  that  the  anes- 
thetist should  be  held  to  that  degree  of  care,  skill,  and  knowledge  ordi- 
narily possessed  by  practitioners  in  good  standing  devoting  special  at- 
tention and  study  to  the  administration  of  anesthetics.  As  a  rule,  the 
surgeon  is  responsible  to  the  family,  while  the  anesthetist  is  responsible 
to  the  surgeon;  but  if  the  anesthetist  has  been  specially  called  in  by 

^  Force  v.  Gregory,  63  Conn.,  167;  Bowman  v.  Woods,  1  Greene  Iowa,  441; 
Corsi  V.  MaretseTc,  4  E.  D.  Smith,  N.  Y.,  1;  Williams  v.  Poppleton,  3  Or.,  131; 
Hesse  v.  Enippel,  1  Mich.  N.  P.,  109. 

°  Martin  v.  Courtney,  77   N.  W.,   813. 

^  Baker  v.  Hancock,  63  N.  E.,  323;   64  N.  E.,  38;  S9  Ind.  App.,  456. 

*  Baker  v.  Hancock,  63  N.  E.,  323. 

^  Feeney  v.  Spalding,  89  Me.,  Ill;  McMurdock  v.  Kimberlin,  23  Mo.  App.  523; 
Stern  v.  Lanng,  106  La.,  738. 


THE  MEDICO-LEGAL   STATUS    OF   THE   ANESTHETIST     685 

the   patient   or    the    practitioner,    he   is   on    the    same    footing    as    the 
surgeon. 

The  Criminal  Liability  of  the  Physician. — The  criminal  liability 
on  the  part  of  a  physician,  for  the  purposes  of  this  discussion,  may  be 
summarized  in  the  following  propositions: 

(1)  Where  the  practitioner  wilfully  adopts  procedure  liable  to 
jeopardize  the  life  or  health  of  the  patient.^ 

(2)  Where  the  practitioner  wilfully  omits  to  adopt  the  procedure 
necessary  in  safeguarding  the  life  or  health  of  the  patient. ^ 

(3)  Where  injury  to  the  patient  results  from  gross  ignorance  or 
negligence  on  the  part  of  the  physician. 

(4)  Where  the  practitioner  is  guilty  of  conduct  prohibited  by 
statute. 

Xo  application  of  the  above  propositions  to  procedure  on  the  part 
of  the  practitioner  can  be  made  without  due  regard  to  the  principle  of 
law  that  one  is  presumed  to  intend  the  natural,  necessary,  and  probable 
consequence  of  his  acts. 

Gross  Ignorance  or  Negligence. — The  liability  on  the  part  of  the 
practitioner  growing  out  of  gross  ignorance  or  negligence  is  of  serious 
concern  to  the  anesthetist  in  view  of  the  occasional  deaths  which  occur 
during  and  immediately  subsequent  to  an  anesthetization. 

It  is  a  monument  to  the  honor  of  the  American  medical  profession 
that  so  few  cases  have  grown  out  of  the  liability  of  the  practitioner 
for  death  resulting  from  gross  ignorance  or  negligence  in  the  adminis- 
tration of  anesthetics  that  the  law  in  this  country  cannot  be  said  to 
be  clearly  defined. 

In  general  it  may  |)e  said  that  the  law  presumes  that  the  practitioner 
has  used  due  care  and  skill,  and  accordingly  the  burden  of  proof  is  on 
him  who  alleges  gross  ignorance  or  negligence.^  This  presumption  re- 
quires the  plaintiff  in  civil  actions  to  prove  his  case  by  a  preponderance 
of  evidence  and  in  criminal  cases  beyond  a  reasonable  doubt. 

The  few  American  decisions  read  in  the  light  of  the  English  law 

^  For  a  discussion  of  the  question,  ' '  Has  the  Physician  Ever  the  Eight  to  Ter- 
minate Life?"  see  55  Albany  Law  J.,  136;  and  Haeckel:  "Wonders  of  Life," 
1905,  116. 

^  Where  the  death  of  a  person  results  from  the  criminal  negligence  of  the  prac- 
titioner in  the  treatment  of  a  case,  the  latter  is  guilty  of  manslaughter:  State  v. 
Eeynolds,  42  Kan.,  320;  Uyatt  v.  Adams,  16  Mich.,  198;  State  v.  Gile,  8  Wash., 
12.  The  real  question  upon  which  criminal  liability  depends  is  whether  there 
was  criminal  negligence,  which  is  hardly  a  matter  of  degree.  On  the  facts  con- 
stituting criminal  negligence,  sec  State  v.  Hardister,  38  Ark.,  605;  Com.  v.  Pierce, 
133  Mass.,  165 ;  Bex  v.  Long,  4  C.  and  P.,  398 ;  WeM  's  case,  2  Lewin  C.  C,  196 ; 
and  Beg.  v.  Chamberlain,  10  Cox  C.  C,  486. 

'  Pettigretv  v.  Lewis,  25  Pac.  E.,  458 ;  Feeney  v.  Spalding,  80  Me.,  111. ;  FecTc  v. 
ButcMnson,  55  N.  W.,  511;  Wohlert  v.  Siehert,  23  Pa.  Super.,  214;  Georgia  North- 
ern By  Co.  V.  Ingram,  40  S.  E.,  708. 


686  ANESTHESIA 

indicate  that  the  courts,  in  ascertaining  the  responsibility  of  the  prac- 
titioner when  death  has  resulted  from  the  administration  of  anesthetics, 
consider  three  classes  of  facts,  viz.:  (1)  the  necessity  of  the  operation; 
(3)  the  competency  of  the  operator;  (3)  whether  the  wound  or  injury 
would  have  proved  mortal  without  the  operation. 

Among  the  pertinent  inquiries  which  arise  in  determining  gross 
ignorance  or  negligence  under  this  classification  of  facts  are  the  kind 
and  fitness  ^  and  quality  of  the  anesthetic  administered,  the  method  of 
administration  followed,  the  consent  ^  of  the  patient  to  its  administra- 
tion, the  peculiar  condition  or  temperament  of  the  patient,  if  necessary 
and  relevant,  and  the  circumstances  permitting  of  their  acquirement,^ 
skill  in  the  use  of  instruments,  and  proper  qualifications  *  of  and  in- 
structions to  those  in  immediate  charge  of  the  patient  as  to  the  use  of 
medicines,^  a  disregard  of  which  by  the  practitioner,  if  found  gross, 
renders  him  criminally  responsible.  Hence,  it  will  be  seen  that  criminal 
malpractice  in  this  respect  differs  from  civil  malpractice  only  in  degree. 
In  defining  criminal  malpractice  in  a  leading  case,  the   Court  said:^ 

'^Criminal  negligence  exists  where  the  physician  or  surgeon,  or  per- 
son assuming  to  act  as  such,  exhibits  gross  lack  of  competency,  or  gross 
inattention,  or  criminal  indifference  to  the  patient's  safety,  and  this 
may  arise  from  his  gross  ignorance  of  the  science  of  medicine  or 
surgery  and  of  the  effects  of  the  remedies  employed,  through  his  gross 
negligence  in  the  application  and  selection  of  remedies  and  his  lack  of 
proper  skill  in  the  use  of  instruments,  or  through  his  failure  to  give 
proper  instructions  to  the  patient  as  to  the  use  of  the  medicines." 

It  is  important  to  mention  here  that  it  has  been  held  by  the  Supreme 
Court  of  Vermont  that  a  physician  administering  an  anesthetic  is  not 
liable  for  not  protesting  against  an  operation  not  favored.'^ 

Statutory  Liability. — To  determine  the  statutory  liability  on  the 
part  of  the  practitioner,  it  is  necessary  to  examine  the  statutes  of  the 
several  States.  As  indicated  above,  they  have  their  origin  in  the  police 
power  of  the  State.     Other  than  those  statutes  which  prohibit  the  per- 

'^  Bogle  V.  Winslow,  5  Phila.  Keports,  136. 

^  Mehr  v.  Williams,  95  Minn.,  261.  Actions  have  been  brought  in  England  for- 
alleged  anesthetization  without  consent.  In  these  cases,  the  patient  and  anesthet- 
ist, who  was  also  the  operator,  were  alone  together ;  but  they  failed  on  the  grounds 
that  anesthetization  by  force  was  impossible  and  that  there  was  collateral  evi- 
dence of  consent. 

For  discussion  of  consent  from  an  English  anesthetist 's  point  of  view,  see 
J.  D.  Mortimer:     "Anesthesia  and  Analgesia,"  1911,  255. 

^  Lewis  V.  Dwinel,  84,  Me.,  497;  Logan  v.  Field,  75  Mo.  App.,  594. 

*  For  qualifications  of  a  trained  nurse,  see  Art.  12,  Public  Health,  Law,  State 
of  New  York,  1909. 

^  Kampton  v.  State,  50  Fla.,  55. 

°  Hampton  v.  State,  39  Southern  E.,  424. 

'75  Atl.  Eept.,  641. 


THE  MEDICO-LEGAL   STATUS   OF   THE   ANESTHETIST     GS7 

formance  of  illegal  operations  ^  and  the  treatment  of  a  patient  by  a 
physician  under  the  influence  of  intoxicants,  with  the  exception  of 
Ohio,  which  prohibits  the  administration  of  anesthetics  except  in  the 
presence  of  a  third  party  who  must  be  a  competent  witness,^  none  of 
the  States  has  passed  statutes  directly  affecting  the  anesthetist.  An 
anesthetic  should  not  be  administered  without  the  presence  of  an  as- 
sistant or  a  third  person,  except  in  cases  of  emergency;  and,  in  the  ab- 
sence of  a  professional  assistant,  the  operator  must  assume  the  entire 
responsibility.  If,  however,  the  assistant  is  duly  licensed,  the  responsi- 
bility is  assumed  by  both. 

Finally,  it  may  be  said  that,  in  the  administration  of  anesthetics, 
whether  by  physician,  surgeon,  dentist,  anesthetist,  or  other  professional 
assistant,  the  practitioner  should  at  all  times  exercise  the  highest  de- 
gree of  caution,  for  it  is  not  only  difficult  to  determine  the  proximate 
cause  of  death  in  cases  where  an  anesthetic  has  been  used,  but  women, 
particularly  young  women,  are  likely  to  have  erotic  sensations  while 
under  its  influence,  and  thus  an  added  responsibility  may  be  brought  to 
the  practitioner  in  defending  his  good  character  and  fidelity  of  pur- 
pose.^ 

1  No  one  may  give  an  anesthetic  for  an  illegal  operation. 

2  ' '  Whoever  uses  upon  another  an  anesthetic,  unless  at  its  administration,  and 
during  the  whole  time  the  person  is  v^holly  or  partly  under  the  direct  influence  of 
it,  there  is  present  a  third  person  competent  to  be  a  witness,  shall  be  fined  not 
more  than  Twenty-five  Dollars  nor  less  than  Five  Dollars"  (Laning's  "Rev. 
Stat.,"  10685). 

3  Sexual  intercourse  with  a  woman  while  she  is  unconscious  has  been  held  to 
be  against  the  will  of  the  woman  and  without  her  consent  so  as  to  constitute  rape : 
Com.  V.  Burke,  105  Mass.,  377;  Com.  v.  Childs,  S  Pgh.,  398;  Lewis  v.  State,  30 
Ala.,  54;  Shirwin  v.  People,  69  111.,  55.  An  attempt  to  administer  chloroform  to 
a  woman  for  the  purpose  of  having  sexual  intercourse  with  her  while  she  is  under 
its  influence  is  an  attempt  to  rape:    Milton  v.  State,  2i  Texas  App.,  284. 

As  to  chloroform  as  a  means  of  facilitating  crime,  see  Vroc.  N.  ¥.  Med.  Leg. 
Sac,  1872,  298-317;  cf.  also  Sogers  v.  State,  33  Ind.,  543. 

However,  in  an  interesting  pamphlet  by  Stephen  Rogers  on  chloroform  (Har- 
per and  Bros.,  New  York,  3877),  it  is  argued  with  much  force  that  for  the  pur- 
poses of  attack  chloroform  cannot  be  effectively  used.  See  also:  3  Whart.  and 
St.  Med.  J.,  245,  594;  and  Wharton's  "Criminal  Law,"  1896,  1,  527.  But  cf. 
Ford  V.  State,  41  Tex.  Crim.,  270;  State  v.  Greene,  2  Ohio  Dec,  255;  2  West.  L. 
Month.,  185. 

For  cases  of  conviction  for  rape  committed  on  a  woman  under  the  influence 
of  ether,  see  State  v.  Green,  3  Whart.  and  St.  Med.  J.,  597;  and  Com.  v.  Beale, 
ibid.,  245,  596,  612. 

On  alleged  murder  by  inhalation  of  chloroform  to  sleeping  unconscious  victim, 
see  Fairchild:  Medico-Legal  J.,  24,  19,  34. 

For  a  discussion  of  the  question,  "Can  Chloroform  Be  Used  by  Inhalation  to 
Commit  Murder,  Robbery  or  other  Crime  on  an  Unconscious  Victim,"  Bell: 
Medico-Legal  J.,  24,  28. 

On  "The  Medico-Legal  Questions  Arising  in  the  Case  of  Patrick,"  Bell: 
Medico-Legal  J.,  22,  494,  529. 


CHAPTEE     XX 

A    LIST    OF    ANESTHETICS  1 

Including  General  Anesthetics,  Local  Anesthetics,  and  Anesthetic  Mix- 
tures, Both  Past  and  Present,  With  Synonyms 

While  local  anesthetics  may  be  regarded  as  nothing  more  than  strong 
hypnotics,  so  far  as  possible  anesthetics  have  been  carefully  discrim- 
inated from  hypnotics.  However,  hypnotics  employed  as  adjuvants  have 
been  included. 

Anesthetic  sequences  are  not  included,  except  in  exceptional  cases, 
as,  for  example,  those  not  referred  to-  elsewhere  in  the  text  of  this  work. 
Such  substances  as  atropin,  phenylacetyl,  homatropin,  ortho-chlor-cocain,  • 
meta-nitro-cocain,  vanillin,  piperonal,  etc.,  which  have  little  or  no  pro- 
nounced anesthetic  action,  or  whose  anesthetic  action  is  obscure,  and 
which  have  never  been  employed  in  practice  for  the  production  of  an- 
esthesia or  whose  effects  have  never  been  the  cause  of  complaint  among 
workmen  in  industries,  are  not  considered.  While  the  effects  of  some 
of  the  many  dental  anesthetics  may  be  due,  at  least  in  part,  to  the  re- 
sults of  pressure,  yet  the  authors  have  adhered  to  the  plan  of  present- 
ing a  full  and  complete  list  of  these.  The  preparations  termed  "eye 
drops"  have  been,  in  general,  omitted. 

A.  C.  E.  Mixture. — A  mixture  of  A(lcohol),  C(hloroform),  and 
E(ther),  intended  for  a  safer  and  quicker  anesthetic  than  either  in- 
gredient alone.  The  theoretical  neutralization  of  the  bad  effects  of  the 
one  anesthetic  by  the  good  effects  of  the  others  and  an  intensifying  of 
the  anesthetic  qualities  have  not  been  realized  in  practice. 

^  In  the  Am.  Drug,  and  Fharm.  Bee,  Feb.  13  and  27,  and  Mar.  13,  1911,  one 
of  the  authors  (C.  B.)  published  "A  List  of  Anesthetics";  but  a  number  of 
omissions  occurred  in  this  very  brief  paper,  and  the  insertions  necessitated  for 
completion  of  the  list,  together  with  fuller  descriptive  matter  and  bibliographical 
data,  are  included  here.  The  plan  has  been  to  present  a  complete  list  of  all 
anesthetics,  both  past  and  present;  consequently,  by  no  means  all  mentioned  are 
in  use  or  on  the  mafket.  A  number  of  preparations  which  include  anesthetics  in 
their  composition  are   given. 

The  authors  are  indebted  to  a  number  of  manufacturers  for  information  con- 
cerning their  products;  but,  wherever  possible,  the  information  presented  has 
been  taken  from  the  literature.  We  are  especially  grateful  to  Dr.  Eobert  H. 
Ferguson  for  helpful  suggestions. 

688 


A   LIST    OF    ANESTHETICS  689 

Mixtures  began  with  Pitha  to  be  used  in  18G1  (Wiener  med.  Woch., 
1861,  25  and  26).  In  England,  George  Hartley  is  said  to  have  used 
them  and  to  have  introduced  the  alcohol  before  1864.  He  proposed  the 
A.  C.  E.  Mixture,  now  commonly  known,  which  is  often  referred  to  as 
the  L.  M.  &  C.  S.  (London  Med.  and  Chir.  Soc.)  Mixture,  since  this 
society  investigated  and  recommended  it  in  1864  (Med.-Chir.  Trans., 
London  Med.  and  Chir.  Soc,  ^7,  341,  342).  As  defined  by  them  it 
consists  of: 

Alcohol  (sp.  gr.,  0.838),  1  part; 

Chloroform  (sp.  gr.,  L497),   2  parts;  and 

Ether  (sp.  gr.,  0735),  3  parts. 

Mix. 

For  other  combinations  of  alcohol,  chloroform  and  ether,  see  Martin- 
dale's  Mixture,  Eeyne's  Anesthetic  Mixture,  Billroth's  Mixture,  Nuss- 
haum's  Mixture,  Bicliardsons  Mixture,  Vienna  General  Hospital  Mix- 
ture, and  Vienna  Anesthetic. 

Acetaldehyd. — Poggiale  found  aldehyd  to  be  a  prompt  and  ener- 
getic anesthetic,  but  Simpson  stated  that  it  produced  irritation  and 
dyspnea. 

Francis  and  Fortescue-Brickdale  ("The  Chemical  Basis  of  Phar- 
macology," 1908,  107)  state  that  in  acetaldehyd  "the  anesthetic  prop- 
erties are  more  marked  (than  in  formaldehyd),  and  still  more  pro- 
nounced in  its  polymeric  form  paraldehyd,  which  is  not  so  toxic  as 
metaldehyd."     See  Paraldehyd. 

Acetic  Ether. — See  Ethyl  Acetate. 

Acetofonn.— Acetoform  is  a  brand  name  for  acetone-chloroform. 
Acetoform  dusting-powder  consists  of  acetoform  1  part  and  boric  acid 
47  parts.     See  Chloretone  and  Methaform. 

Acetone. — Acetone  (Dimethylketone;  Dimethylketal ;  Ketopropane; 
Methylacetyl ;  Pyroacetic  Ether),  CH3.CO.CH3,  produces  intoxication 
and  sleep;  it  is,  however,  less  powerful  in  action  than  ethyl  ether  or 
chloroform,  and  is  less  toxic  than  ethyl  alcohol.  It  possesses  anesthetic 
properties.     See  Propion. 

Acetone-Chloroform. — See  Chloretone  and  Methaform. 
■  Acetylene. — One  per  cent  of  acetylene  in  air  is  said  to  produce  nar- 
cosis with  failure  of  heart  and  respiration.  Lauder  Brunton  has  indi- 
cated that  the  characteristic  action  of  aliphatic  hydrocarbons,  such  as 
acetylene,  ethylene,  propylene,  butylene,  amylene,  etc.,  is  on  the  nerve 
centers,  tending  to  produce  first  excitement  and  then  narcosis;  they  act 
on  the  sensory  side.  On  the  other  hand,  the  aromatic  hydrocarbons 
(see  Benzene,  e.  g.)  act  mainly  on  the  motor  side,  producing  convul- 
sions and  paralysis.  On  these  points,  see  Francis  and  Fortescue-Brick- 
dale :    "The  Chemical  Basis  of  Pharmacology,"  1908,  45. 


690  ANESTHESIA 

On  the  toxicology  of  acetylene,  see  Kosemann :  Arch.  f.  exper.  Path, 
u.  Pharmacol.,  1895,  36;  Moissan:  Compt.  rend.,  121;  Mosso  and  Otto- 
lengui:  Rend,  della  R.  Accad.  del  Lincei,  1896;  and  Oliver:  Brit.  Med. 
J.,  1898,  1. 

Acetylene  Dichlorid. — See  Dioform. 

Acetylene  Tetrachlorid. — See  Tetrachlor ethane. 

Acidum  Amidobenzoicum  ^thylatum. — See  Anesthesin. 

Acoin    or    Acoine     (Di-para-anisyl-monophenetyl-guanidin    hydro- 

NH< >0CH,.HC1 

chlorid:  "Acoine  C"/C:N<ZZI>0C,HA A  local   (dental  and  oph- 
NH< >0CH, 

thalmic)  anesthetic,  also  used  in  Sehleich's  infiltration  anesthesia. 

Acoin  is  the  collective  name  of  the  alkyloxy-phenyl-guanidin  group 
of  which  the  hydrochlorid  of  di-para-anisyl-monophenetyl-guanidin  is 
clinically  especially  important.  Acoine  is  obtained  in  the  form  of  a 
white  powder  which  fuses  at  176°  F.  It  is  readily  soluble  in  alcohol, 
and  water  at  63°  F.  will  dissolve  6  per  cent  of  its  weight  of  acoin. 
Its  solutions  are  said  to  be  powerful  antiseptics  and  a  solution  of  0.02 
per  cent  in  a  nutritive  medium  will  prevent  the  development  of  anthrax 
spores.  A  1  per  cent  solution  will  not  decompose  for  a  long  time  if  kept 
in  a  dark  place,  but  should  be  kept  in  non-soluble  glass.  Strong  solu- 
tions of  acoin  have  corrosive  properties  and  consequently  are  not 
adapted  for  subcutaneous  or  endermal  application;  a  1  per  cent  solution 
or  one  which  is  even  less  concentrated  accomplishes  anesthesia,  and  it  is 
said  that  it  can  be  used  without  bad  results,  either  immediate  or  remote. 

On  the  anesthetic  properties  and  applications  of  acoin,  see  the  fol- 
lowing : 

Trolldenier:    Therap.  Monatsh.,  1898,  No.  1,  36. 

Guibert:    Clin.  Ophthal.,  1899,  No.  17. 

Darier:    Clin.  Ophthal.,  1899,  No.  12. 

Hirsch :    Archiv  f.  Augenlieil.,  Jf2,  No.  3. 

Randolph :    Ophthal.  Rec,  Aug.,  1899. 

Carter:    Lancet,  Oct.  21,  1899. 

Braun:    Kocher's  "Enzyklopadie  der  Chir./'  1900. 

Trolldenier:   Z.  f.  Thiermedicin,  1901,  80. 

Stasinski:    Therap.  der  Gegenwart,  1901,  No.  5. 

Senn,  Schw. :    Yrtljschr.  f.  Zahnheil.,  10,  No.  4. 

Etievant:  La  Provence  Med.,  Lyon,  July  14,  1900. 

Nipperdey:    Deut.  Monatschr.  f.  Zahnheil.,  Nov.  20,  1902. 

Spindler:    Wratsch.  Gaz.,  1902,  No.  14. 

Daconto:    Deut.  Z.  f.  Chir.,  69,  457. 

Bab :    Wiener  Zahndrztl.  Monatsh.,  1902. 


A   LIST    OF    ANESTHETICS  691 

On  acoin  in  combination  with  cocain  ("Acoincocain")  as  a  local 
anesthetic,  see: 

Darier :    "Legons  de  therapeutique  oculaire,"  Paris,  1902. 
Kraus:   Munch,  med.  Woch.,  1903,  1459. 

On  acoin  for  purposes  of  dental  surgery,  see : 

Bab  :    Jour.  f.  Zahnheilkunde,  1903,  No.  1. 

Simon:    Dental  Cosmos,  Jan.,  1904. 

Krakowski:    Subowpatschebny  Wjestnik,  1901,  No.  8. 

Acoincocain. — See  Acoin. 

Acoin  Oil. — This  is  a  one  per  cent  solution  of  acoin  base  in  peanut 
oil  and  is  used  principally  in  eye  diseases. 

Acoinol. — This  does  not  contain  acoin  hydrochlorid,  but  1  per  cent 
of  acoin  base. 

Adralgin. — An  anesthetic  for  dental  and  surgical  practice  contain- 
ing thymol,  cocain,  and  adrenalin  (epinephrin)  in  physiological  salt 
solution.     This  preparation  is  marketed  by  a  Swiss  firm  in  ampules. 

Adralgin  Chirurgicum. — This  contains  in  2  c.  c.  0.015  gm.  thymol- 
cocain  compound  and  0.0001  gm.  adrenalin. 

Adralgin  Dentale. — This  contains  0.01  thymol-cocain  compound  and 
0.000051  gm.  adrenalin. 

Adrenalin  and  Cocain  Tablets. — Each  hypodermic  tablet  contains 
cocain  hydrochlorid  0.01  gm.  (1/6  grain)  and  adrenalin,  as  borate, 
0.0002  gm.  (1/300  grain). 

Esch  (Arch.  f.  e.vp.  Path.  u.  Pharm.,  6-^,  84)  reported  that  the  addi- 
tion of  adrenalin  to  novocain,  alypin,  and  especially  cocain  intensified 
their  local  narcotic  action. 

Adrenalin-Kokain-Tabletten. — These  small  cylindrical  tablets  con- 
tain 0.0002  gm.  adrenalin  and  0.01  gm.  cocain  hydrochlorid;  they  are 
used  in  dentistry. 

Adricain. — This  is  a  dental  anesthetic  tablet  containing  adrin  1/100 
gr.  and  cocain  hydrochlorid  1/10  gr.,  marketed  by  a  Philadelphia  firm. 

Adrin  and  Cocain  Tablets. — Tablets  of  epinephrin  and  cocain.  (For 
dental  practice.)  Each  tablet  contains  adrin,  0.00065  gm.  (1/100  gr.) 
and  cocain  hydrochlorid,  0.016  gm.  (14  gr.). 

.ffither  Anaestheticus  Aranii. — In  the  chlorination  of  ethyl  chlorid 
isomers  are  obtained,  and  these  are  also  produced  in  the  manufacture 
of  chloral.  A  variable  mixture  of  the  middle  members  of  the  series  is 
Liquor  Ansestheticus.  Another  similar  mixture,  containing  the  less 
chlorinated  bodies,  is  the  ^ther  Ansestheticus  Aranii,  which  boils  be- 
tween -f-  64°  and  -f- 100°  C.     The  composition  of  Aran's  ether  has  been 

CCI3 
given   as  (sp.   gr.,    1.55 — 1.60;   b.  p.,    -1-130°    circa);   but   its 

CHCL 


692  ANESTHESIA 

composition  is  very  variable  and  it  has  been  considered  unsafe  as  an 
anesthetic.  It  is  not  used  at  present.  See  Lyman's  "Artificial  Anaes- 
thesia and  Anesthetics,"  204. 

.ffither  AnaestheticTis  Konig. — A  local  anesthetic  composed  of  alco- 
hol-free ether,  1  part,  with  4  parts  of  rhigolene  or  petroleum  ether. 

.aither  Ansestheticus  Wiggers. — This  anesthetic  contains  the  more 
highly  chlorinated  products  referred  to  under  ^ther  Anaestheticus 
Aranii,  and  boils  between  +  100°  and  -f  140°  C.  See  Ethyl  Cldorid 
Polychlorated. 

JEther  Chloratus.— See  Ethijl  Chlorid. 

^tho-Methyl. — A  mixture  of  ethyl  and  methyl  chlorids,  prepared 
by  a  Mayence  firm.     See  Pharm.  Ztg.,  1ft ,  916. 

.aithoxycaffein. — Used  with  sodium  salicylate  (Ceola).  ^thoxy- 
caffeine  (CgHg.OCjHg.N^Oa)  is  obtained  by  heating  monobrom-caf- 
fein  with  an  excess  of  alcoholic  potassium  hydroxid.  It  forms  white 
or  colorless  crystals,  melting  at  -|-  140°  C,  and  soluble  in  hot  alcohol 
and  in  ethyl  ether.    The  solubility  is  increased  by  sodium  salicylate. 

^thylenum  Chloratum. — See  EihyUne  Chlorid. 

^thyliuiii  Amidobenzoicum. — An  anesthetic. 

.31thyli-iiin  Aminobenzoicum. — See  Anesthesin. 

.ffithyloform. — A  mixture  of  ethyl  bromid,  ethyl  chlorid,  and  methyl 
chlorid. 

Air. — In  1867  an  American  dentist  advertised  that  he  "now  takes 
teeth  out  painlessly  by  merely  causing  the  patient  to  inhale  the  con- 
stituents of  the  atmosphere — oxygen  and  hydrogen  ( !) — chemically 
combined."  (Chem.  News,  16,  26.)  Mtrous  oxid  was  undoubtedly 
referred  to. 

Alcohol  Phenicum. — See  Carbolic  Acid. 

Alcool  Trichloramidoethylique. — See  Chloralformamid. 

Allocain. — This  is  a  mixture  of  novocain  and  alypin  {q.  v.),  recom- 
mended, in  combination  with  synthetic  suprarenin  and  thymol,  as  a 
local  anesthetic  in  tooth  extraction  by  Proskauer  {Z.  Zahnheilk.,  1911, 
No.  17). 

Flury  {Z.  angew.  Chem.,  26,  No.  35,  242)  describes  allocain  as  a 
mixture  of  novocain,  alypin  and  adrenalin. 

Alvatunder. — A  local  anesthetic  said  to  contain  1  gm.  cocain  hydro- 
chlorid,  3  drops  of  liquid  phenol,  3  drops  of  decolorized  tincture  of 
iodin,  10  gm.  glycerin,  and  water  to  100  gm. 

Alypin. — Alypin  is  2-benzoxy-2-dimethyl-amino-methyl-l-dimethyl- 
amino-butane  hydrochlorid,  CH3.CH2.C(CeH,COO)  (CH2N(CH3),). 
CH,N(CH3)2.HCl=:Ci6H2602N,.HCl.  It  is  closely  related  to  Sto- 
vain  {q.  v.). 

By  the  action  of  dichloracetone,  CHoCl.CO.CH„Cl,  on  ethyl-mag- 
nesium bromid  dissolved  in  ether  and  decomposition  by  water  of  the 


A   LIST    OF    ANESTHETICS  69^ 

magnesium  compound  formed,  ethyl-diehlorhydrin,  CIl2Cl.C(C.H./) 
(0H.)CH2C1,  is  obtained.  From  this,  by  the  action  of  dimethylamin, 
ethyl-tetramethyl-diamino-propanol  is  produced.  This  product  is  treated 
with  benzoyl  chlorid  and  the  benzoyl-ethyl-tetramethyl-diamino-pro- 
panol  is  neutralized  with  hydrochloric  acid  to  form  the  chlorid. 

Alypin  is  a  white  crystalline  powder,  melting  at  -J- 169°  C.  (336.2° 
F.),  hygroscopic  and  extremely  soluble  in  water.  Its  solutions  are 
neutral  and  are  not  rendered  turbid  on  addition  of  sodium  bicarbonate 
in  moderate  quantities,  and  may  be  sterilized  by  boiling  for  a  period 
not  exceeding  five  minutes,  without  decomposition.  It  is  easily  soluble 
in  alcohol.     It  has  a  markedly  bitter  taste. 

It  should  be  protected  from  the  air  in  well-stoppered  containers. 
Two  and  four  per  cent  solutions  are  quite  stable,  but  weaker  solutions 
are  likely  to  become  mouldy. 

Addition  of  potassium  iodid  test  solution  to  the  aqueous  solution 
(1-100)  produces  a  white  precipitate;  potassium  dichromate  test  solu- 
tion produces  a  yellow  crystalline  precipitate  soluble  in  hydrochloric 
acid;  potassium  permanganate  test  solution  produces  a  violet  crystalline 
precipitate,  which  turns  brown  on  standing.  If  0.1  gm.  alypin  be  mixed 
with  1  c.  c.  sulphuric  acid  and  warmed  to  -(-  100°  C.  (212°  F.)  for  five 
minutes  and  then  2  c.  c.  water  carefully  added,  the  odor  of  benzoic-ethyl- 
ester  is  developed;  on  cooling,  crystals  separate  out,  which  are  dissolved 
on  adding  2  c.  c.  alcohol.  If  alypin  is  dried  at  -f  100°  C.  (212°  F.), 
the  loss  should  not  exceed  1.5  per  cent. 

Actions  and  Uses. — It  is  a  local  anesthetic,  claimed  to  be  equal  to 
cocain,  but  not  a  mydriatic;  it  is  said  not  to  produce  disturbance  of 
accommodation  and  to  be  less  toxic  than  cocain.  It  has  been  highly 
recommended  in  ophthalmic  practice,  and  is  said  to  be  safe  and  effi- 
cient in  nose,  throat,  and  ear  work,  general  surgery  (spinal  analgesia, 
infiltration  anesthesia),  and  dentistry.  Internally  it  acts  as  a  sedative. 
With  regard  to  the  manner  of  use,  the  strengths  of  solutions  employed 
are  about  the  same  as  those  of  cocain.  Sterilization  may  be  effected  by 
boiling  the  required  amount  of  water  for  ten  minutes  in  a  small  flask 
or  test-tube  stoppered  with  cotton;  alypin  is  then  added  and  the  boiling 
continued  over  a  small  flame  for  another  minute.  The  solutions  should 
be  freshly  prepared.  Alypin  is  compatible  with  alkaline  solutions  and 
with  suprarenal  preparations.  According  to  Schleich,  the  addition  of 
alypin  to  cocain  in  infiltration  anesthesia  permits  of  larger  quantities  of 
fluid  being  used,  the  solutions  proposed  by  him  being  as  follows :  (1)  Co- 
cain, 0.1;  alypin,  0.1;  sodium  chlorid,  0.2;  and  distilled  water,  100. 
(2)  Cocain,  0.05;  alypin,  0.05;  sodium  chlorid,  0.2;  distilled  water, 
100.  (3)  Cocain,  0.01;  alypin,  0.01;  sodium  chlorid,  0.2;  distilled 
water,  100. 

Dosage. — Externally  in  the  form  of  a  10  per  cent,  solution;  hypo- 


694  ANESTHESIA 

dermically  in  1  to  4  per  cent  solutions;  for  the  eye  in  1  to  2  per  cent 
solutions.  As  much  as  5  c.  c.  of  a  3  per  cent  solution  was  well  tolerated 
in  one  case. 

Alypin  Tablets,  3  1/3  grains.  Each  tablet  contains  0.22  gm.  (3  1/3 
grains)  of  alypin. 

Alypin  Tablets,  li/s  grains.  Each  tablet  contains  0.073  gni.  (1% 
grains)  of  alypin. 

Alypin  Tablets,  %  grain.  Each  tablet  contains  0.048  gm.  (%  grain) 
of  alypin. 

Alypin  Tablets,  1/3  grain.  Each  tablet  contains  0.022  gm.  (1/3 
grain)  of  alypin. 

For  further  particulars  concerning  alypin,  which  has  been  widely 
tested  therapeutically,  consult  the  following  literature,  chronologically 
arranged : 

Impens:   Veut.  med.  Woch.,  1905,  1154. 

Seifert:  Ibid.,  1905,  No.  34. 

Stotzer:   Ibid.,  1905,  No.  36. 

von  Kraus:   Ibid.,  1905,  No.  49,  1966. 

Peckert:    Deut.  Zahndrztliche  Woch.,  1905,  No.  43,  721. 

Braun :   Deut.  med.  Woch.,  1905,  No.  42,  1669. 

Jakobsohn :   Woch.  f.  Therapie  und  Hygiene  des  Auges,  1905,  No.  52. 

Gebb:   Aerztl  Rundsch.,  1905,  No.  39. 

Geth:    Dissert.  Giessen,  1905. 

Seeligsohn:   Deut.  med.  Woch.,  1905,  No.  35. 

Stephenson:    Ophthalmoscope,  Nov.,  1905. 

von  Sicherer:    Ophthal.  Klinik,  1905,  No.  16. 

Neustatter:    Miinch.  med.  Woch.,  1905,  No.  42,  2015. 

Ohm:    Woch.  f.  Therapie  und  Hygiene  des  Auges,  1905,  No.  6,  41. 

Kollner:   Berl.  Jclin.  Woch.,  1905,  No.  43. 

Landolt:   Woch.  f.  Therapie  und  Hygiene  des  Auges,  9,  No.  16,  122. 

KauflFmann:   Aerztl.  Eundsc,  1906,  No.  9,  97. 

Steindorff :    "Sammelreferat  und  eigene  Beobachtungen,"  1906. 

Sendral:     Revue  de  Therap.,  1906,  No.  9,  297. 

Massi :     Boll,  del  Osped.  oftalmico  di  Roma,  1906,  No.  1. 

Kirchner:    Ophthalmol.  Klinik,  1906,  No.  7. 

Kraus:    Miinch.  med.  Wocli.,  1906,  No.  29,  1443. 

True:     Revue  Generale  d' Ophthalmol.,  Mar.  31,  1906. 

Darier:  CZm.  0^/i^/iaL,  1906,  No.  4. 

Kuoli:  Westnih  oftalmologie,  1906,  No.  6;  Petersburger  med. 
Woch.,  1906,  Eevue  No.  8,  25. 

Weil:    Allg.  med.  Centr.-Ztg.,  1905,  No.  36. 

Haass:   Woch.  f.  Therapie  und  Hygiene  des  Auges,  1906,  No.  50. 

Zimmermann:    Klin.  Monats.  f.  AugenheilTc.,  1906,  No.  9. 

Wibo:    J.  Med.  de  Bruxelles,  1906,  No.  4. 


.A   LIST    OF   ANESTHETICS  695 

Koll:    Z.  f.  drztliche  Forthildung,  1906,  ISTo.  6. 

Castresana:    Siglo  medico,  May  16,  1906. 

Cohen:  J.  Am.  Med.  Assn.,  July  38,  1906. 

Fischer :    Gyogydszat,  1906,  No.  7. 

Baumgarten:    Wien.  Tclin.  liundsc,  1906,  No.  36,  676. 

Finder :  .Berl.  hlin.  Woch.,  1906,  No.  5,  130. 

Sternberg:    Aerztl.  Rundsc,  1905,  No.  38. 

Katz:   Deut.  med.  Woch.,  1906,  No.  36. 

Joubeline:  Russkij  Wratsdt.,  December  31,  1905;  Revue  de  Therap., 
1906,  No.  4,  131. 

Euprecht:   Monatssch.  f.  Ohrenheil.,  1906,  No.  6. 

Dold:  Korrespond.  des  wurttemherg.  drztl.  Landesvereins,  1906, 
No.  26. 

Anten:    Scapel,  1906,  No.  50. 

Venus:    Wiener  klin.  Rundsc,  1906,  No.  51. 

Eaoult-Pillement :    Archiv  Internat.  de  Laryng.,  Sept.,  1906. 

Freudenthal:    Critic  and  Guide,  May-June,  1906. 

Borszeky:    Orvosi  Hetilap,  1906,  No.  25. 

Gilles:    Zahndrztl.  Rundsc,  1906,  Nos.  22  and  23. 

Phillips:    Laryngoscope,  July,  1906. 

Dehogues:    L'Odontologie,  1906,  No.  5. 

Lohnstein:    Deut.  med.  Woch.,  1906,  No.  13,  504. 

Chevallier:  Miinch.  med.  Woch.,  1906,  No.  14,  683;  Klin.-therap. 
Woch.,  1906,  No.  12,  282. 

Mahler:    Deut.  zahndrztl.  Woch.,  1906,  No.  127. 

Tauszk:    Wiener  med.  Ztg.,  1906,  No.  12. 

Cooper:   Denver  Med.  Times,  Nov.,  1906. 

Wanietschek:  Prager  med.  Woch.,  1906,  No.  50;  Allg.  med.  Centr.- 
Ztg.,  1907,  No.  38,  582. 

Laufer:    Reichs-Medizinal-Anzeiger,  1907,  No.  17. 

Borbely:    Pester  med.-chir.  Presse,  1907,   No.  31. 

Shulebin:  Mitteil.  der  militdr-med.  Alcad.,  St.  Petersburg,  1907, 
176. 

Biirkner:   Berl.  klin.  Woch.,  1907,  389. 

Euprecht:    Monats.  f.  Ohrenheil.,  1907,  No.   6. 

Spira:    Die  Heilkunde,  1907,  No.  9. 

Kurzwelly:    Beitr.  z.  klin.  Chir.,  1907,  No.  3. 

Meyer:  N.  Y.  Med.  J.,  Apr.  27,  1907. 

Dittmer:    Monatsh.  f.  praktische  Tierheilk.,  1907,  No.  5. 

Frank:   Am.  J.  Ophthal.,  Nov.,  1907. 

DuFour:    Ya.  Med.  Semi-Month.,  Jan.  24,  1908. 

Lewis :  J.  Am.  Med.  Assn.,  May  9,  1908. 

Bremerman:    Surg.  Gynec.  and  Obstet.,  Nov.,  1908. 

Winslow:   Hosp.  Bull  of  Univ.  Md.,  Jan.  15,  1908. 


696  ANESTHESIA 

Gwathmey:    Va.  Med.  Semi-Month.,  Nov.  13,  1908. 
Zaun:    Milwaukee  Med.  J.,  June,  1909. 
Green:    Brit.  Med.  J.,  July  34,  1909. 
Lokey:    Atlanta  J.-Rec.  of  Med.,  July,  1909. 
Littlejohn :    Yale  Med.  J.,  Oct.-Nov.,  1909. 

Knight :   "Diseases  of  the  Nose,  Throat,  and  Ear,"  2nd  ed.,  1909. 
Keyes:    "Diseases  of  the  Genito-Urinary  Organs,"  1910. 
Senator:    Miincli.  med.  WocJi.,  1910,  No.  10,  534. 
Bruck :   Merck's  Reports,  1909,  169. 
Hamm:    Deut.  med.  Wocli.,  1910,  No.  35,  1198. 
Bubenhofer:    Munch,  med.  Woch.,  1909,  No.  43. 
Fleissig:  Med.  Klinik,  1910,  No.  5. 
Eisert:    Zahndrztl.  Rundsc,  1910,  No.  30. 
Peters:    Deut.  zahndrzt.  Woch.,  1910,  No.  10. 
Fischer:    Deut.  med.  Woch.,  1910,  No.  38,  1759. 
Barringer:    Fol.  urolog.,  Mar.,  1910. 
Goldschmidt :   Miinch.  med.  Woch.,  1910,  No.  43,  3341. 
Voigt:   Berl.  klin.  Woch.,  1910,  No.  46,  3113. 
Garasch:    Wratsch,  1911,  No.  33. 
Eitter:    Med.  Klinik,  1913,  1336. 

Euprecht:  Monatsh.  f.  Ohrenheilkunde  u.  Laryngo-Rhinologie,  1911^ 
No.  3. 

Alypin-Gleitmittel. — Tragacanth,  13  gm. ;  glycerin,  36  gm. ;  mercury 
oxycyanid,  1  gm. ;  distilled  water,  370  gm. ;  and  alypin,  31  gm.  Used 
for  anesthetization  of  the  urethra  by  means  of  Utzmann's  imguent 
injector. 

Alypin  Nitrate. — Alypin  (q.  v.)  is  incompatible  with  silver  nitrate; 
it  is  therefore  not  well  adapted  for  anesthetizing  mucous  membranes 
to  which  silver  nitrate  is  afterward  to  be  applied,  since  it  may  to  some 
extent  neutralize  the  effect  of  the  latter  through  chemical  decomposi- 
tion. Alypin  nitrate  is  said  to  overcome  this  difficulty,  and  it  is  there- 
fore recommended  in  such  cases.  Its  chemical  characters,  solubility,  and 
strength  of  solutions  are  said  to  correspond  essentially  to  those  of  aly- 
pin. It  is  a  white  powder,  fusing  at  +159°  C,  and  soluble  in  water, 
chloroform,  and  alcohol. 

Alypinoids. — Tablets  containing  alypin  and  suprarenin,  for  use  in 
dentistry. 

Alypin-Tabletten. — 0.03-0.3  gm.  alypin,  with  or  without  suprarenin 
borate.     See  Dolonephran. 

American  Painless  Dentists'  Anesthetic. — This  dental  anesthetic  is 
said  to  contain  nitroglycerin,  cocain  hydrochlorid,  morphin  hydrochlorid, 
listerin,  and  water. 

Amidin. — See  Holocain  Hydrochlorid. 


A   LIST    OF    ANESTHETICS  697 

Aminobenzoic  Acid  Ethyl  Ester  (Para-). — See  Anesthesin. 
Aminobenzoic  Acid  Isobutyl  Ester. — See  Cydoforrn. 
Aminobenzoyldiethylaminoethanolum    Hydrochloricum     (Para-) . — 

See  Novocain. 

Aminocinnamic  Acid  Alkamine  Esters. — These  are  stated  (Meister 
Lucius  and  Briining:  German  Patent  187,593)  to  have  several  times  the 
local  anesthetic  power  of  those  of  aminobenzoic  acid. 

Aminocinnamic  ethyl  ester  is  said  to  have  met  with  little  success 
commercially. 

Ampules  Solution  Atoxyl,  10  per  cent,  with  Novocain,  1  per  cent 
(Sterilized). — Each  100  c.  c.  contain:  atoxyl,  10  gm.,  and  novocain,  1 
gm.  (each  fluid  ounce  contains :  atoxyl,  48  gm.,  and  novocain,  4  8/10  gm., 
dissolved  in  distilled  water. 

Amydricain. — A  local  anesthetic. 

Amyl  Chlorid. — Richardson  (Sci.  Am.  SuppL,  No.  515,  8227)  gave 
the  physiological  properties  of  this  compound  as  follows :  Odor  of  vapor 
slightly  pungent.  Quantity  of  fluid  required  for  complete  anesthesia, 
6  to  8  fluid  drachms.  Required  charge  of  air,  10  per  cent.  Action 
slow,  with  very  slight  rigidity  in  second  stage.  Anesthesia  extremely 
profound  and  prolonged.  Animal  temperature  much  reduced.  Re- 
covery rapid  when  it  commences.  Vomiting  frequent.  The  great 
peculiarity  in  the  action  of  amyl  chlorid  is  in  the  reduction  of  animal 
temperature.  In  one  instance  recorded  by  Richardson,  in  a  rabbit,  the 
temperature  fell  from  -)-  103°  F.  to  -f-  83°  F.,  yet  perfect  recovery,  in 
warm  air,  followed.  According  to  the  same  authority,  the  anesthesia  is 
too  slow  and  profound  for  ordinary  practice,  but  might  be  valuable  for 
reduction  of  high  febrile  temperatures.  After  death,  cardiac  action  is 
long  persistent;  the  blood  is  fluid,  but  of  natural  color  on  both  sides. 
The  red  corpuscles  are  shrunken  and  elongated,  with  truncated  ends, 
some  stellate.  The  brain  is  left  bloodless  and  of  purest  white. 
Amyl  chlorid  was  introduced  by  B.  W.  Richardson  in  1869. 

Amyl  Hydrid.— This  compound,  introduced  as  an  anesthetic  by  J. 
Bigelow  and  B.  W.  Richardson  in  1867,  has,  according  to  the  latter 
(Sci.  Am.  Suppl.,  No.  515,  8227),  the  following  physiological  prop- 
erties :  Vapor  odorless  and  free  from  pungency.  Quantity  of  fluid  re- 
quired, 6  to  12  fluid  drachms  for  complete  anesthesia.  Required  charge 
of  air  by  vapor,  40  per  cent.  Anesthesia  is  very  rapid,  being  profound 
in  two  minutes,  with  a  short  period  of  spasmodic  movements.  Recovery 
is  very  rapid,  without  vomiting,  and  the  temperature  of  the  body  is  un- 
changed. According  to  Richardson,  the  anesthetic  action  is  extremely 
rapid,  but  dangerous,  probably  from  the  insolubility  of  the  vapor  in  the 
blood.  The  heart  is  easily  paralyzed,  but  irritability  of  the  voluntary 
muscles  is  long  retained. 

See  Hydramyl  and  Pentene. 


698  ANESTHESIA 

On  death  from  the  inhalation  of  a  mixture  of  ether  and  amyl  hy- 
drid,  see  Hardie,  Lancet,  April,  1875. 

Amyl  Nitrite  (Isoamyl  Nitrite). — Amyl  nitrite  was  first  brought 
into  notice  by  Guthrie  in  1859,  and  was  made  the  subject  of  investiga- 
tion by  Eichardson  in  1863-5  and  1870;  by  Eutherford,  Gamage,  and 
Brunton  in  1869 ;  by  Wood  in  1871,  by  Landendorf  in  1874,  by  Bourne- 
ville  in  1875,  and  at  various  times  by  a  number  of  other  investi- 
gators. 

Eichardson  states  that  amyl  nitrite  is  absorbed  by  the  bodies  of 
animals,  however  introduced.  The  effects  of  the  compound  are  most 
conspicuous  upon  the  motor  apparatus  of  the  body,  especially  upon  the 
vascular  motor  apparatus.  Its  effects  upon  the  power  of  sensation  are 
not  as  early  apparent;  hence  it  is  often  considered  to  be  devoid  of 
anesthetic  properties.  Consciousness,  however,  may  disappear  before 
death  from  its  use. 

Brunton  believed  that  amyl  nitrite  diminished  the  blood  pressure 
by  a  local  effect  upon  the  walls  of  the  smaller  arteries.  Wood  demon- 
strated that  amyl  nitrite  diminished  motor  energy  and  reflex  excita- 
bility. 

Amyl  nitrite  is  well  known  for  its  supposed  efficacy  as  an  antidote 
to  chloroform  in  cases  of  impending  death  during  the  inhalation  of  the 
vapor  of  the  anesthetic.  A  mixture  of  amyl  nitrite  and  chloroform  has 
been  experimented  with,  in  the  hope  of  thus  procuring  a  greater  degree 
of  safety  than  with  chloroform  alone  (see  Med.  Bee,  Oct.  5,  1878). 
See  CMoramyl. 

Amylene  (Beta-isoamylene;  trimethylethylene ;  valerene;  pentene). — 
This  highly  inflammable  compound  was  proposed  as  an  anesthetic  by 
John  Snow  in  1856;  it  has  been  used  as  a  dental  anesthetic,  but  great 
caution  is  necessary.     See  Trim  ethyl  e  thy  I  e?ie  and  Pental. 

Amylene  was  found  to  produce  a  loss  of  sensibility  without  causing 
complete  coma  or  stupor.  Although  Snow  introduced  it  as  a  substitute 
for  chloroform,  it  was  found  not  to  be  so  safe  an  agent.  See  Med. 
Times  and  Gaz.,  Apr.  4,  1857,  332;  Apr.  18,  1857,  381;  and  Aug.  8, 
1857,  133.  The  French  Academy  of  Medicine  formally  condemned 
amylene  as  a  dangerous  anesthetic  soon  after  its  introduction. 

Eichardson  {Sci.  Am.  Suppl.,  No.  515,  8227)  stated  that  the  "odor 
of  its  vapor,  like  wood  spirit,  was  not  pungent.  Quantity  of  fluid  re- 
quired for  complete  anesthesia,  4  to  8  fluid  drachms.  Eequired  charge 
of  air  by  vapor,  15  per  cent.  Anesthesia  rapidly  produced,  with  short 
but  sharp  second  or  spasmodic  stage.  Consciousness  sometimes  appar- 
ently retained  during  insensibility,  as  in  somnambulism.  Eecovery  rapid, 
with  freedom  generally  from  all  after-effect.  Vomiting  extremely  rare." 
Eichardson  stated,  however,  that  the  anesthetic  value  of  amylene  was 
doubtful.     It  caused  two  deaths  in  238  administrations  between  Nov., 


A   LIST    OF   ANESTHETICS  699 

1856,  and  July,  1857.     "Sudden  failure  of  cardiac  motion  is  the  source 
of  danger  from  amylene." 

It  may  be  mentioned  here  that  Mering  introduced  amylcne  hydrate 
as  a  hypnotic  in  1887. 

On  amylene  anesthesia,  see  also  Li  von :  Compt.  rend.  Hoc.  de  Biol., 
•1903,  55,  143. 

Amylenechloral. — This  alcoholate,  formed  by  the  combination  of 
chloral  and  amylene  hydrate,  is  Di-methyl-ethyl-carbinol-chloral, 

CCl3.CH.0H.0.C(CH,,),.C2H5. 
It  is  colorless  and  possesses  a  density  of  1.24;  its  odor  is  camphor-like 
-and  the  taste  is  slightly  caustic.     It  is  insoluble  in  cold  water,  but  is 
miscible  to  any  desired  extent  with  alcohol,  ethyl  ether,  acetone,  and 
fatty  oils. 

Fuchs  and  Koch  (Munch,  med.  WocTi.,  1898,  No.  37,  1175)  investi- 
gated the  properties  of  amylenechloral,  finding  it  to  be  productive  of 
certain  sleep,  deeper  than  that  induced  by  chloral  hydrate,  when  admin- 
istered subcutaneously  or  per  os  in  dogs.  It  appeared  to  be  equivalent 
to  other  hypnotics,  such  as  paraldehyd,  amylene  hydrate,  etc.,  and  for 
this  reason  is  included  here. 

Amylocain. — A  local  anesthetic. 

Anemogenol. — A  dental  anesthetic  containing  novocain  and  supra- 
renin. 

Anemorenin. — This  preparation  consists  of  5  c.  c.  of  a  1  per  cent 
solution  of  suprarenal  extract,  and  another  solution  containing  per  c.  c. 
0.003  gm.  of  tropacocain  hydrochlorid  and  0.002  gm.  of  sodium  chlorid. 
The  solutions  are  mixed  before  use.  Moller  describes  "anemorenin"  as 
specially  adapted  for  dental  purposes.  See  Moller:  Zahndrztl.  Rmid- 
schau,  1902,  No.  532,  9353. 

Anesthesin.— This  local  anesthetic,  ethyl-para-amido-benzoate,  NH,- 
CgH^.COOCoHs,  was  first  prepared  in  1890  by  Eitsert,  and  was  intro- 
duced as  a  substitute  for  cocain.  It  is  obtained  by  the  reduction  of 
ethyl-para-nitro-benzoate  by  means  of  zinc  and  hydrochloric  acid,  and 
forms  a  fine  white  crystalline  powder  melting  at  -|-  90-91°  C,  and  is 
easily  pulverized.  It  is  almost  insoluble  in  cold  water,  difficultly  soluble 
in  hot  water,  but  readily  soluble  in  ethyl  ether,  alcohol,  benzene,  and 
fatty  oils.  It  dissolves  in  almond  oil  to  the  extent  of  2  per  cent,  in  olive 
oil  to  3  per  cent,  and  those  oleaginous  anesthesin  solutions  are  said  to 
be  sterilizable  without  decomposition.  Anesthesin  is  decomposed  into 
para-amido-benzoic  acid  and  alcohol  on  long-continued  boiling  with 
water  or  on  warming  it  with  dilute  solutions  of  the  alkalies. 

Anesthesin  was  investigated  from  a  pharmacological  standpoint  by 
Robert  and  Binz  {Berl.  klin.  Woch.,  1902,  No.  17).  Experiments  on 
animals  determined  that  there  was  no  danger  from  the  use  of  anesthesin 
in  therapeutic  doses.     Clinical  trials  led  to  the  same  conclusion.     In 


700  ANESTHESIA 

physiological  activity  anesthesin  is  on  a  parallel  with  orthoform  {q.  v.)  ; 
it  is  said  to  be  equally  effective,  but  free  from  irritant  action  and  tox- 
icity. It  is  said  to  quickly  render  insensible  to  painful  operations  sensi- 
tive nerves  with  which  it  conies  in  contact,  and  to  subdue  pain  with  the 
same  certainty  as  orthoform.  The  most  delicate  tissues  are  said  to 
tolerate  anesthesin  without  the  slightest  symptom  of  irritation.  The 
anesthetic  action  resembles  that  of  cocain,  but  is  purely  local;  it  does 
not  penetrate  the  mucous  membranes.  In  consequence  of  its  insolu- 
bility, anesthesin  cannot  be  used  by  hypodermic  injection.    See  Cocainol. 

Some  of  the  extensive  literature  on  anesthesin  follows: 

von  Noorden :  "On  Ethyl-para-amido-benzoate  as  a  Local  Anaes- 
thetic," Berl  Min.  Woch.,  1902,  No.  17. 

Dunbar :  "Contribution  to  Local  Anaestliesia  with  Ethyl-para-amido- 
benzoate,"  Deut.  med.  WocJi.,  1903,  Nos.  10,  20,  and  22. 

Lengemann :  "Anesthesin  in  the  Treatment  of  Wounds,"  Centr.  f. 
Chir.,  1902,  No.  22. 

Kassel:  "Employment  of  Ansesthesin,"  Therap.  Monatsh.,  July, 
1902,  386. 

Eammstedt:  "On  the  Employment  of  Anesthesin  Hydrochlorate 
(Ritsert)  for  Local  Anesthesia,"  Centr.  f.  Cliir.,  192,  No.  38. 

Schaeffer-Struckert :  "Dr.  E.  Eitsert's  Anesthesin ;  Its  Employment 
in  Dentistry,"  Vort.  a.  d.  Kongr.  Zahndrz.  in  Milnch.,  Aug.  5,  1902. 

Hartmann:  "Employment  of  Anesthesin  in  Surgical  Practice," 
Therap.  der  Gegenwart,  Oct.,  1902,  No.  10. 

Spiess:  "Anesthesin,  a  New  Local  Anesthetic,  from  the  Point  of 
View  of  the  Remedial  Action  of  Anesthesin,"  Miinch.  med.  Woch., 
1902,  No.  39,  1611. 

Geyer :  "Practical  Experiences  with  Cocainol  Preparations," 
Reichs-Med.-Anz.,  Nov.,  1902,  No.  23. 

Scherer :  "A  Report  on  Four  Cases  Treated  with  Anesthesin,'"'  Med. 
and  Surg.  Mon.,  Nov.,  1902,  No.  11. 

Glas:  "Anesthesin  Treatment  in  Laryngeal  Cavities."  Read  in 
the  Session  of  the  Vienna  Laryngological  Society,  December  3,  1902, 
(Ref.:     Wie7ier  Min.  Woch.,  Jan.,  1903,  No.  1.) 

Earp :  "A  Report  of  Cases  in  Which  Good  Results  Were  Partly  or 
Wholly  Due  to  Anesthesin,"  Cincin.  Lancet  Clin.,  Dec.  13,  1902; 
Merck's  Archives,  1903,  27. 

Chevalier :    "Anesthesin,"  Rev.  d.  Therap.,  Dec,  1902,  No.  24,  835. 

Kennel:  "Anesthesin  (Dr.  Ritsert),  A  Therapeutical  Trial,"  Bei-l. 
Min.  Woch.,  Dec,  1902,  No.  52,  1218. 

Pollatschek:  "Contribution  to  the  Treatment  of  Laryngeal  Tuber- 
culosis," Magyar  OriosoJt  Lapja,  Jan.,  1903,  No.  1. 

Henius:  "Anesthesin  in  the  Treatment  of  Erysipelas,"  Therap.  d. 
Gegenwart,  Jan.,  1903 ;  Merck's  Archives,  1903,  99. 


A   LIST    OF   ANESTHETICS  701 

Maramaldi:  '^Ansesthesin,"  Giornale  inter,  delle  scienze-medische, 
Jan.  31,  1903,  No.  2. 

Duhot :  "Anaesthesin :  Its  Applications  in  Urology  and  Dermo- 
syphilography,"  Ann.  d.  I.  Policlin.  Central,  de  Brux.,  Feb.,  1903,  No.  3. 

Courtade :  "Anaesthesin  in  Ehino-laryngology,"  Rev.  d.  Therap., 
March  1,  1903;  Alle.  Wiener  med.  Zeit.,  March,  1903,  No.  12;  Nou- 
veaux  remedes,  1903,  No.  4,  73. 

Duplan :  "Contribution  to  the  Study  of  Angesthesin,"  Inaugural- 
Dissertation,  Paris,  March  25,  1903. 

Lorand:  "Contribution  to  the  Pathology  and  Therapeutics  of  the 
'Pruritus  vulvae'  of  Diabetes,"  La  Policlinique,  Briissel,  March  15,  1903. 

Kobert:  "Ansesthesin  as  a  Dental  Anaesthetic,"  Pharm.  Zeitung, 
1903,  No.  41,  413. 

Haug:  "Anffisthesin  in  the  Treatment  of  Inflammations  of  the 
Aural  Passages  and  for  Local  Anaesthesia  in  Paracentesis,"  Archiv  f. 
Ohrenheill.,  1903,  58,  Nos.  3  and  4,  267. 

Lengemann:     Wiener  med.  Presse,  1903,  1010. 

Hoenigschmied :    Die  Heilkunde,  1904,  No.  2. 

Imhofer:    Prager  med.  Woch.,  1904,  Nos.  4  and  5. 

Eeinburg:    Bull.  gen.  de  therap.,  Feb.  23,  1904. 

Duhot:    Ann.  d.  I.  Policlin.  Central,  de  Brux.,  1904,  No.  2. 

YioUet :     Gaz.  d.  Hop.,  1904,  Nos.  23  and  25. 

Freudenthal:    Med.-Pharm.  Critic  and  Guide,  1904,  No.  3. 

Scherer:    Med.  and  Surg.  Mon.,  1904,  No.  5. 

Lotheissen:     Wiener  Jclin.  Rundsc,  1904,  No.  44. 

Ivuhnt:    Deut.  med.  Woch.,  1905,  No.  34. 

Baccarani:     Soc.  Med.-chir.  di  Modena,  Seduta  del  7  aprile,  1905; 

Baumgarten :    Budapesti  Orvosi  Ujsdg,  1905,  No.  13. 

Easp :    Excerpta  Medica,  1905,  No.  5. 

Finder:    Berl.  klin.  Woch.,  1905,  No.  8. 

Eeiss:     Therap.  d.  Gegenwart,  1905,  No.  10. 

Kassel:     Z.  filr  OhrenheilJc.,  1905,  No.  1. 

Vohsen:    Berl.  Min.  Woch.,  1905,  No.  40. 

Saxtorph-Stein :      Hospitalstidende,   1905,    No.    34    and    35    (Eef 
Deutsche  Med.-Zeit.,  1906,  No.  24). 

Choronshitzky :    Monats.  f.  Ohrenheil.,  1905,  No.  1. 

Klingmiiller :     Deutsche  med.  Woch.,  1905,  No.  29. 

Lublinski:    Berl.  hlin.  Woch.,  190Q,'^o.  52. 

Freund:     Therap.  d.  Gegenwart,  1906,  No.  6. 

Eeissner:     Deutsche  zahndrtzl.  Zeit.,  1906,  No.  123. 

Drucker:    Budapesti  Orvosi  Ujsdg,  1907,  No.  15. 

Avellis:    Miinch.  med.  Woch.,  1907,  No.  11. 

Bruhn:     Therap.  Neuheiten,  1908,  No.  2. 

Hoffman:    Miinch.  med.  Woch.,  1908,  No.  14. 


702  ANESTHESIA 

Payr:    Med.  Klinik,  190S, 'No.  18. 

Frese:    Med.  Klinik,  1908,  No.  16. 

Karabinski:     Aerztlicher  Central-Anzeiger,  1909,  No.   17. 

Eitter-Bier:  Vortrag  auf  der  38.  Verhandlungen  der  deutschen 
Gesellschaft  .fiir  Chirurgie,  13-17  April,  1909.  Allg.  med.  Central- 
Ztg.,  1909,  No.  21. 

Pinner  and  Siegert:    Berl.  hlin.  Wocfi.,  1909,  No.  22. 

Fackelmann:    Allg.  med.  Central-Ztg.,  1911,  No.  3,  32. 

Anaesthesin  Solubile  (Dr.  Ritsert). — According  to  Pharm.-Ztg.,  If!, 
460,  this  is  a  form  of  Ritsert's  anesthesin  marketed  by  a  Frankfort  firm. 

Anaesthesin  Bomelin. — Bormelin  containing  10  per  cent  anesthesin. 

Anaesthesinum  Solubile. — See  Suhcutin. 

Anaesthesinum  Sulfophenylicum. — See  Suhcutin. 

Anesthol. — A  liquid  of  red  color,  ethereal  odor,  and  bitter  taste, 
used  as  a  local  anesthetic  in  dental  practice  in  Germany. 

Anesthetic  Mixture  (Reynes). — This  consists  of  chloroform,  2  parts; 
ether  and  absolute  alcohol,  1  part  each.  Coblentz :  "The  Newer  Reme- 
dies," 4th  ed.,  12;  Gehe's  Codex,  Nov.,  1910,  21. 

Anaesthetica  Tabletten. — A  German  dental  anesthetic  for  injection 
into  the  gums,  containing  atropin  sulphate,  0.0003  gm. ;  morphin  hydro- 
chlorid,  0.005  gm. ;  cocain  hydrochlorid,  0.01  gm. ;  potassium  ortho-oxy- 
chinolin-sulphonate,  0.0007  gm. ;  and  sodium  chlorid,  0.014  gm.  One  to 
two  tablets  are  dissolved  in  2  to  4  c.  c.  of  water. 

Anaestheticum. — A  dental  anesthetic,  said  to  be  a  10  per  cent  solu- 
tion of  cocain  in  phenyl  acetate. 

Anaestheticum  (Edison's). — This  contains  chloral,  30  parts;  alcohol, 
110  parts;  chloroform,  90  parts;  camphor,  60  parts;  oil  of  cloves,  59 
parts ;  oil  of  peppermint,  59  parts ;  ethyl  ether,  50  parts ;  salicylic  acid,  5 
parts;  amyl  nitrite,  3  parts;  and  morphin  sulphate,  2  parts  (Coblentz: 
"The  Newer  Remedies,"  4th  ed.,  12). 

Anaestheticum  Bottwini. — A  mixture  of  3  parts  by  weight  each  of 
menthol  and  crystalline  phenol,  with  1  part  of  cocain  hydrochlorid. 

Anaestheticum  Gray. — See  Gray's  AncBstheticum. 

Anaestheticum  Witte. — A  dental  local  anesthetic,  consisting  of  a  so- 
lution of  methylbenzoylecgonin  hydrochlorid  and  hydroiodid  in  solution 
in  sterilized  physiological  salt  solution  containing  iodin  and  phenol. 

Anaesthin  and  Anaesthol  (Speier). — A  mixture  of  five  parts  of  ethyl 
chlorid  and  1  part  of  methyl  chlorid.  Employed  as  a  local  anesthetic 
by  spraying.     See  Z.  angew.  Chem.,  1901,  261. 

Anaesthol  Katz. — A  local  anesthetic  containing  methyl  chlorid  and 
ethyl  chlorid. 

Anaesthol  (W.  Meyer);  Weidig's  Anaesthol;  Anesthol. — Schleich 
("Schmerzlose  Operationen,"  II  Aufi.,  Berlin,  1897)  endeavored  to  im- 
prove general  anesthesia  by  starting  from  a  physical  instead  of  from  a 


A   LIST    OF    ANESTHETICS  703 

chemical  basis.  Without  ignoring  any  of  the  important  points  in  ad- 
ministration, he  attempted  to  adapt  the  boiling  point  of  the  narcotic  to 
the  temperature  of  the  body.  As  is  well  known,  chloroform  possesses  a 
boiling  point  considerably  above  the  body  temperature,  while  ethyl 
ether  boils  somewhat  below  the  same.  In  consequence  thereof,  Sohleich 
reasoned  that  chloroform,  when  administered  by  inhalation  for  the  pro- 
duction of  narcosis,  is  absorbed  by  the  blood  in  larger  amount  than  is 
really  necessary  for  the  purpose.  Furthermore,  since  it  is  eliminated  by 
the  organism  gradually,  it  overtaxes  all  the  parenchymatous  organs,  in- 
juring, as  a  result  thereof,  their  cells.  On  the  other  hand,  ether  is  va- 
porized so  rapidly  Avhen  inhaled  that  it  will  not  enter  the  blood  if  the 
alveoli  do  not  first  become  overfilled  with  carbon  dioxid,  producing  pri- 
mary cyanosis  and  dyspnea.  To  quote  Willy  Meyer  {Med.  Rec,  Aug. 
15,  1908)  :  "It  is  with  the  onset  of  this  cyanotic  condition,  it  seems, 
that  the  narcotic  effect  of  the  ether  begins.  Although  the  elimination 
of  ether  almost  keeps  pace  with  its  absorption,  the  slight  excess  that 
remains  in  the  blood  is  sufficient  to  affect  the  brain  and  produce  uncon- 
sciousness. The  greatly  accelerated  rhythm  of  breathing,  which  in- 
creases the  amount  of  oxygen  inhaled,  facilitates  the  elimination  of 
carbon  dioxid  by  the  laws  of  diffusion  of  gases  involved  in  normal  res- 
piration." It  follows  from  this  reasoning  that  the  essential  condition 
for  the  regular  elimination  of  ether  in  a  state  of  vapor  is  an  absolutely 
intact  lung — one  able,  if  required,  to  perform  an  abnormal  amount  of 
work. 

In  view  of  the  preceding,  Schleich  sought  a  safer  narcotic  which 
would  not  tax  the  parenchymatous  organs  or  the  lung  tissue,  and  one 
possessing  a  boiling  point  corresponding  to  the  body  temperature,  in 
order  that  the  amount  eliminated  during  expiration  should  be  about 
equal  to  that  absorbed  during  inspiration.  He  finally  selected  a  com- 
bination of  chloroform,  ether,  and  petroleum  ether  (benzin),  the  latter 
being  added  for  the  purpose  of  diminishing  the  toxic  effects  of  chloro- 
form upon  the  system.  Schleich  employed  three  mixtures  (see 
Schleich:    "Ansesthetics"). 

Notwithstanding  the  position  taken  by  Dawbarn  {Atlanta  Med. 
Surg.  J.,  Sept.  and  Oct.,  1897)  and  others,  it  is  a  fact  that  in  practice 
mixtures  have  proved  to  be  safer  than  ether  or  chloroform  alone  (on 
this  point  see  Meyer:  J.  Am.  Med.  Assn.,  Feb.  28,  1903).  English 
anesthetists  have,  for  instance,  experienced  great  success  with  A.  C.  E. 
mixture  {q.  v.),  and  it  has  also  been  reported  from  Vienna  that  Vienna 
mixture  {q.  v.)  possesses  great  safety.  Schleich  maintained  that  such 
anesthetic  mixtures  were  chemical  solutions,  not  mixtures,  possessing  a 
boiling  point  differing  from  that  of  any  of  the  components.  Ellis 
("Ana3sthesia  with  Mixed  Vapors,"  London,  1866)  had  earlier  found 
that,  when  London  Medical  and  Chirurgical  Mixture  A.  (alcohol,  1  part; 


704  ANESTHESIA 

chloroform,  2  parts;  and  ether,  3  parts)  was  evaporated,  during  the  six 
or  seven  minutes  required  for  the  evaporation  of  tvi^o  grams  of  the 
liquid,  the  vapor  of  ether,  almost  exclusively,  was  given  off  during  the 
first  minute,  the  vapor  of  chloroform  predominated  during  the  next 
three  minutes,  and  the  evaporation  of  alcohol  occupied  the  last  three 
minutes. 

H.  P.  Weidig,  of  Newark,  JSF.  J.,  found,  on  analyzing  Schleich's  an- 
esthetic mixtures,  that  "they  contain  a  permanent  nucleus — a  chemical 
combination  of  chloroform  and  ether,  according  to  their  molecular 
weight"  (Meyer:  J.  Am.  Med.  Assn.,  Feb.  28,  1903).  Meyer  reports 
that  43.25  parts  of  pure  chloroform  by  volume  and  56.75  parts  of  abso- 
lute ether  by  volume,  mixed  together,  "enter  into  chemical  combina- 
tion" (see  "M.  S."),  forming  "a  stable  molecular  solution,"  which  re- 
sists fractionation  to  the  last,  and  which  has  an  evaporating  point  of  its 
own.  According  to  Weidig  (see  Meyer,  Loc.  cit.),  Schleich's  mixtures 
contain  "this  fixed  molecular  solution  of  chloroform  and  ether  ("M.  S.") 
plus  36  to  53  per  cent  (in  volume)  of  free  ether,  plus  petrolic  ether, 
the  latter  most  probably  not  in  chemical  combination."  Meyer  there- 
fore concluded  that  patients  subjected  to  general  anesthesia  by  means 
of  Schleich's  mixtures  inhale  in  the  beginning  of  the  narcosis  ether 
plus  "M.  S."  plus  petrolic  ether.  After  the  ether  and  petrolic  ether 
have  evaporated  the  narcosis  continues  with  "M.  S."  Meyer  considered 
Schleich's  principle  of  improving  general  anesthesia  on  a  physical  basis 
to  be  correct,  but  was  obliged  to  abandon  the  use  of  his  mixture,  in  view 
of  the  findings  of  Meltzer  (N.  Y.  Med.  Bee,  1898,  607;  Aug.  15,  1908), 
whose  experiments  showed  that  petrolic  ether  had  no  narcotizing  power 
and  produced  paralysis  of  the  respiratory  muscles  if  administered  in 
large  amount. 

After  numerous  experiments  during  1897  and  1898,  Weidig  and 
Meyer  tried  ethyl  chlorid  as  a  substitute  for  petrolic  ether,  and  found 
that  a  mixture  of  18  per  cent  by  volume  of  ethyl  chlorid  plus  82  per 
cent  by  volume  of  "M.  S."  possessed  a  boiling  point  of  -|-  100.4°  F. 
(-j-  38°  C),  that  17  per  cent  by  volume  of  ethyl  chlorid  plus  83  per 
cent  by  volume  of  "M.  S."  had  a  boiling  point  of  +  104°  F.  (+  40°  C), 
and  that  16  per  cent  by  volume  plus  84  per  cent  of  "M.  S."  had  a  boiling 
point  of  +  107.6°  F.  (+  42°  C).  Meyer  proposed  that  only  the  second 
mixture  be  used,  namely,  that  containing  83  per  cent  by  volume  of 
"M.  S."  plus  17  per  cent  by  volume  of  ethyl  chlorid,  and  he  used  this 
new  mixture,  which  was  termed  "anesthol"  or  "ansesthol,"  for  the  first 
time  on  October  15,  1898,  in  an  interval  operation  for  appendicitis. 
Meyer  has  stated  {Med.  Bee,  Aug.  15,  1908)  that  the  combination  was 
trade-marked  "anesthol"  by  the  manufacturers  much  against  his  will, 
but  it  is  not  patented,  and  has  been  marketed  also  under  the  name 
"ansesthol." 


A   LIST    OF    ANESTHETICS  705 

Anesthol  is  a  clear,  transparent  liquid  of  very  agreeable  odor,  pos- 
sessing a  density  of  1.045  and  a  boiling  point  of  -f  1<^4°  F.  (-f-  40°  C). 
"It  is,"  to  quote  Meyer,  "a  chemical  combination  of  ethyl  chlorid  and 
M.  S.,  not  a  mixture;  for,  on  evaporating  1,000  c.  c.  of  anesthol  for 
five  hours  at  a  uniform  temperature  of  +  104°  F.,  22  c.  c.  (2.2  per  cent 
by  volume),  with  a  specific  gravity  of  1.262,  were  left.  .  .  .  This 
fact  proves  that  up  to  the  last  moment  a  'solution  of  components'  dis- 
charges, and  does  not  leave  a  final  residual  chloroform,  .  .  .  as  is 
the  case  in  Schleich's  mixtures  (Weidig)."  Weidig  found,  upon  analy- 
sis, that  anesthol  contains  17  per  cent  of  ethyl  chlorid,  35,89  per  cent 
of  chloroform,  and  47.10  per  cent  of  ether  (method  of  analysis  not 
stated  in  Meyer's  communications).  "Gelie's  Codex"  (Nov.,  1910,  22) 
gives  the  composition  of  "ansesthol  Meyer"  as:  17  per  cent  ethyl  chlo- 
rid, 31,7  per  cent  ether,  and  51.5  per  cent  chloroform.  In  the  same 
place  "anesthol"  is  described  as  a  mixture  of  chloroform,  43.25;  ether, 
56.75;  and  ethyl  chlorid,  20.5.  Schleich  later  adopted  the  combination 
recommended  by  Meyer,  substituting  ethyl  chlorid  for  petrolic  ether; 
he  again  proposed  three  different  mixtures,  which,  to  quote  Meyer,  "is 
not  practical." 

Meyer  {Med.  Bee,  Aug.  15,  1908)  stated  that  he  had  used  anesthol 
in  his  hospital  and  private  work  for  ten  years,  and  that  it  was  also  ex- 
tensively employed  by  his  colleagues  at  the  German  Hospital,  New  York. 
Early  in  the  fall  of  1899  they  introduced  the  rule  of  giving  a  hypo- 
dermic of  morphin  about  one  hour  prior  to  the  administration  of  the 
general  anesthetic,  "We  have  used  the  chloroform,  ether,  and  ethyl 
chlorid  mixture  in  many  thousands  of  cases,  .  .  .  and  consider  it, 
when  preceded  by  a  hypodermic  of  morphin,  the  least  dangerous  of  all 
anesthetics  thus  far  known,  especially  in  the  hands  of  comparatively  in- 
experienced anesthetists,  and  this  not  only  as  regards  the  safety  of  the 
patient  while  on  the  operating  table,  but  principally  as  to  the  after- 
effects of  the  anesthetic  (Meyer)," 

On  anesthol,  see  the  following  papers:  Meyer:  J.  Am.  Med.  Assn., 
Feb.  28,  1903;  Meyer:  Munch,  med.  Woch.,  1903,  1221;  Katz:  Deut. 
med.  Woch.,  1903,  431;  Forster:  Centr.  f.  Gyndkol.,  1903,  No.  24; 
Klin.-iherap.  Wocli.,  1903,  No.  32;  Heger:  Pliarm.  Post,  42,  373;  see 
also,  Pharm.  Ztg.,  ^8,  544;  Meyer:    Med.  Bee,  Aug.  15,  1908. 

Eosenthaler  {Archiv  der  Pharmazie,  Berlin,  1906,  244,  24)  found 
that  chloroform  and  ethyl  ether,  both  at  -|-  15.2°  C,  mixed  in  the 
proportion  of  their  molecular  weights,  increased  in  temperature  to 
-f  30.2°  C,  Mme.  and  H.  Marcelet  (Bull.  Sci.  Pharmacol.,  Nov,, 
1912,  676)  also  referred  to  the  disengagement  of  heat  observed  on 
mixing  chloroform  and  ether,  and  they  investigated  the  effects  on  mix- 
ing the  two  liquids  in  varying  proportions,  using  chloroform  which  had 
been  carefully  freed  from  alcohol.     With  a  mixture  of  25  c.  c.  of  each 


ro6 


ANESTHESIA 


liquid,  the  temperature  rose  from  an  initial  of  +  1G.55°  to  -|-  30.3°  C. 
Whether  the  evolution  of  heat  noted  upon  mixing  ether  and  chloro- 
form is  due  to  solution  or  reaction,  the  above  mentioned  authors  did  not 
attempt  to  explain.  With  the  view  of  throwing  some  light  upon  this 
question,  in  §o  far  as  it  pertained  to  the  contention  of  Weidig  (loc.  cit.) 
that  43.25  parts  of  chloroform  and  56.75  parts  of  absolute  ether  by  vol- 
ume, mixed  together,  "enter  into  chemical  eombination,"  Baskerville,^ 

assisted  by  N^eidle,  made  an  experi- 
mental investigation  of  the  rise  of 
temperature  when  chloroform  and 
ethyl  ether  are  mixed. 

The  ethyl  ether  used  in.  the  ex- 
periments performed  by  Baskerville 
and  Neidle  was  "anhydrous  ether"; 
but  it  contained  about  0.1  per  cent 
water  and  0.8  per  cent  ethyl  alcohol. 
Such  a  grade  was  used  because  an 
ether  containing  minimum  quanti- 
ties of  water  and  alcohol  was  de- 
sired. The  chloroform  used  was 
"chloroform,  U.  S.  P.^^  (anesthetic 
chloroform) ;  it  contained  approxi- 
mately 1  per  cent  of  95  per  cent 
ethyl  alcohol. 

In  the  first  experiments  both  the 
chloroform  and  ether  were  taken  at 
-f-  15.3°  C,  in  order  to  repeat  the 
work  of  Rosenthaler.  The  apparatus 
is  shown  in  Figure  280.  As  the 
working  temperature  was  below  the  room  temperature  which  obtained, 
this  was  maintained  by  adding  ice  to  the  water  bath.  On  account  of  the 
greater  volatility  of  the  ether,  in  most  of  the  experiments  the  chloroform 
was  run  out  from  the  constant  temperature  bath  first,  and  then  the  ether 
was  added  to  the  vessel  containing  the  measured  amount  of  chloroform. 
A  small  conical  vessel  with  rather  a  narrow  neck  was  used  for  mixing. 
Results. — From  the  results  presented  in  Table  I  (see  p.  707)  it  will 
be  seen  that  the  maximum  rise  in  temperature  is  obtained  in  the  case  of 
the  molecular  mixture. 

The  investigation  of  Philip  (Z.  jjhysikal.  Chem.,  1897,  ^^,  18)  on 
the  dielectric  properties  of  this  molecular  mixture  indicated  that  it 
might  be  an  individual  chemical  compound.  However,  Baskerville 
and  Keidle  found  that,  on  boiling,  it  behaved  like  a  mixture,  and  not 
like  a  compound;  that  is,  it  begins  boiling,  when  fractionated,  near  the 
^  Charles  Baskerville :     '  *  An  Investigation  of  '  M.  S. '  " 


Fig.  280. — Apparatus  Used  by  Basker- 
ville AND  Neidle.  a,  an  inverted 
bell-jar;  B,  a  rubber-stopper  support- 
ing the  bath  of  water  and  containing 
two  burettes,  one  for  ether  and  the 
other  for  chloroform;  C,  an  arrange- 
ment for  agitating  the  bath  by  means 
of  compressed  air;  D,  a  thermometer. 


A   LIST    OF   ANESTHETICS 
TABLE  I 


707 


Per  Cent  of  Chloroform 

Temperature 

of  mixture  in 

1.  By  volume 

2.  By  weight 

3.  Molecular 

degrees  C. 

11.1 

20.4 

13.9 

23.7 

20.0 

34.1 

24.4 

26.9 

33.3 

50.9 

39.2 

30.6 

42.8 

60.9 

49.1 

32.5 

50.0 

67.5 

56.3 

32.4 

55.6 

72.2 

61.7 

31.9 

60.0 

75.6 

65.9 

31.4 

63.6 

78.4 

69.3 

31.0 

66.6 

80.6 

72.1 

30.1 

69.2 

82.3 

74.4 

29.5 

72.7 

84.7 

77.5 

29.0 

80.0 

89.2 

83.7 

26.9 

88.9 

94.3 

91.2 

23.7 

=  0500 


boiling  point  of  ethyl  ether,  and  gradually  rises  to  the  boiling  point  of 
chloroform.  This  indicated  that  the  heat  developed  when  ethyl  ether 
and  chloroform  are  mixed  was  largely,  if  not  entirely,  heat  of  solution, 
and  that  the  molecular  mixture  gave  the  greatest  increase  in  tempera- 
ture was  accidental.  This  conclusion,  based  upon  the  observations  re- 
corded above,  is  hardly 
supported  by  the  work 
of  Baskerville  and 
Singer,  which  indi- 
cates that  there  is  a 
compound  of  EtgO 
and  CHCI3  existing 
in  equilibrium  with 
the  components  of  the 
solution  (see  Basker- 
ville and  Singer,  in- 
fra). 

In  Table  II  are 
given  the  calculated 
heats  given  out  by  100 
gm.  of  the  various  mix- 
tures, on  the  assump- 
tion that  the  specific  heats  are  additive.  This  assumption  is  justified  by 
the  small  coefficient  of  contraction  even  in  the  case  of  maximum  con- 
traction. If  the  heat  generated  by  mixing  ether  and  chloroform  were 
mainly  attributable  to  the  formation  of  a  molecular  compound,  the  heat 
in  mixture  4  should  be  nearly  three  times  that  in  mixture  1,  for  three 


20         30         40         50  60         70 

Molecular  Per  cent  Chloroform 


80        90 


Fig.  281. 


-Graph   Showing  the   Heat   Generated   by 
Mixing  Ether  and  Chloroform. 


708 


ANESTHESIA 


times  as  much  of  the  compound  could  be  formed.  In  the  graph  repre- 
senting these  quantities  of  heat  (Fig.  381),  a  break  is  observed  at  the 
molecular  mixture,  which  may  be  explained  by  the  large  difference  be- 
tween the  specific  heats  of  ether  and  cliloroform. 

In  Table  III  are  the  calculated  quantities  of  heat  produced  on  add- 
ing successively  increasing  quantities  of  chloroform  to  100  gm.  of  ether. 

Georgiewsky   {J.  Russ.  Pliys.-Chem,.  Soc,  1902,  SJf.,  ii,  565)   gives 

the  coefficient  of  contraction  between  ether  and  chloroform  as  1.4  per 

cent  at  temperatures  between  4-20°   and  -f-  22°    C.     Baskerville  and 

N'eidle  found  the  coefficient  of  contraction  at  -|-  30°   C.  to  be  1.5  per 

cent. 

30° 

Ether  — d  —  =  0.70305 

4° 

30° 
Chloroform  —  d  —  =  1 .  4658 
4° 

30° 
Molecular  mixture  —  d  —  =  1 .0514 
4° 

TABLE  II 


Molecular  per  cent 

Calories  given  out  by 

chloroform 

100  gm.  of  mixture 

1 

13.9 

392 

2 

24.4 

494 

3 

39.2 

577 

4 

49.1 

598 

5 

56.3 

552 

6 

61.7 

523 

7 

65.9 

492 

8 

69.3 
72.1 

467 

9 

432 

10 

74.4 

407 

11 

77.5 

383 

12 

83.7 

310 

13 

91.2 

213 

TABLE  III 


Grams  of  CHCI3  added 
to  100  gm.  of  ether 

Heat  generated  in 
calories 

1 

25.6 
51.7 
103.7 
155.8 
208.6 
259.7 
309.8 
363.0 
415.5 

492 

2 

750 

3 

1175 

4 

1529 

5 

1704 

6. 

7 

8 

1881 
2016 
2162 

9 

2227 

A   LIST    OF    ANESTHETICS 


709 


In  the  experiments  performed  by  Baskerville  and  Singer  "M.  S." 
was  investigated  along  different  lines  from  those  described  above,  in  or- 
der to  ascertain  whether  ether  and  chloroform,  mixed  in  the  proportions 
stated  by  Meyer  {loc.  cit.),  form  a  "stable  molecular  solution." 

Density  of  residual 
solution  at +  23.5°  C. 

After  the  evaporation  of    50  c.c 1 .  0788 

100  " 1.1010 

150  " 1.1134 

200  " 1 .  1325 

250  " 1 .  1469 

300  " 1 .  1640 

350  " 1 .  1866 

The  ethyl  ether  used  possessed  a  density  of  0.7113  at  -)- 23.5°  C; 
the  chloroform,  a  density  of  1.4786  at  -(-  23.5°  C. ;  and  the  "molecular 
solution,"  a  specific  gravity  of  1.0G45  at  -|-23.5°  C.  In  the  preparation 
of  the  "molecular  solution,"  upon  mixing  the  ether  and  chloroform,  con- 
siderable heat  was  developed,  as  noted  by  Baskerville  and  Neidle.  Five 
hundred  c.  c.  of  this  solution  were  placed  in  a  gas  absorption  bottle, 
and  a  regular  current 
of  compressed  air, 
previously  purified, 
was  passed  through, 
the  current  being 
about  the  same  as  that 
used  in  the  Gwathmey 
method  of  vapor  an- 
esthesia. The  vapors 
were  conducted 
through  a  glass  worm 
condenser  and  a  train 
of  Wolff  bottles,  sur- 
rounded by  ice,  but 
very  little  of  the  evap- 
orated solution  could 
be  condensed.  The 
density  of  the  residual 
solution  was  then  determined  after  the  evaporation,  at  room  tempera- 
ture, by  means  of  the  aforesaid  air  current,  of  each  50  c.  c.  The  results 
obtained  from  duplicate  experiments  were  as  given  in  the  table  above. 

The  remaining  150  c.  c.  were  then  removed  from  the  gas  absorp- 
tion bottle,  and  evaporated  down  to  25  c.  c.  This  residue  possessed  a 
density  of  1.3075  at  +  23.5°  C. 

It  will  be  seen  from  these  results  that  the  components  of  the  solu- 
tion do  not  come  off  in  order  under  the  described  conditions:  but  the 


1.2000 
1.1900 
1.1800 
1.1700 
1.1500 
1.1500 
1.1400 
1.1300 
1.1200 
1.1100 
1.1000 
1.0900 


1.0600 
1.0500 


<5 

/ 

/ 

/ 

/ 

y 

/ 

/ 

/ 

/ 

/ 

/ 

/ 

/ 

/ 

/ 

/ 

/ 

' 

/ 

y 

t 

/ 

/ 

/ 

/ 

A 

/ 

/ 

/ 

/ 

y 

/ 

''A 

/ 

y 

/o 

0  50  100         150         200  250  300         350 

AB  =  Ether-Chloroform  Line 
CD  =  Anesthol  Line 

Fig.  282. — Graph  Showing  Densities  of  Residues. 


710  ANESTHESIA 

chloroform  and  ether  are  evaporated  together,  although  the  ether  comes 
off  ill  much  greater  quantity.  The  solution  itself,  of  course,  is  not  a 
chemical  compound,  but  the  results  indicate  that  a  compound  of  chloro- 
form and  ether  exists.  As  Meyer  observed,  a  "solution  of  components" 
is  evaporated)  and  residual  chloroform  does  not  remain. 

In  Figure  282  the  results  obtained  on  "M.  S."  are  shown  by  line 
AB. 

Similar  experiments  were  performed  with  "Dr.  Weidig's  Anaesthol," 
claimed  to  be  a  stable  "chemical  union"  of  35.89  per  cent  chloroform, 
17  per  cent  ethyl  chlorid,  and  47.10  per  cent  ethyl  ether.  The  anesthol 
possessed  a  density  of  1.0538  at  -\-  23.5°  C.  Using  400  c.  c,  and  oper- 
ating as  in  the  case  of  "M.  S.,"  the  following  results  were  obtained : 

Density  of  residual 
solution  at  +  23.5°  C. 

After  the  evaporation  of   50  c  .c 1 .  0815 

"   "      "    "100" 1.1076 

"   "      "    "  150" 1.1344 

"   "      "    "200" 1.1625 

"   "      "    "250" 1.1913 

The  last  25  c.  c.  possessed  a  density  of 1.2590 

In  Figure  282  the  results  obtained  on  anesthol  are  shown  by  line 
CD.  In  the  case  of  anesthol  the  lines  of  distillate  and  residue  are  both 
straight  and  nearly  parallel. 

Undoubtedly  anesthol  contains  a  compound  of  chloroform  and  ether 
in  equilibrium  with  the  components  of  the  solution. 

Ansesthyl  (Anestyle). — A  mixture  of  1  part  methyl  chlorid  and  5 
,parts   ethyl   chlorid,  for   the  production    of   anesthesia  by  freezing  in 
;deiital  operations. 
i        Ansesthyle. — See  Ancesthol  (W.Meyer). 

Ansestiform  (Oppenheimer). — Cocain  hydrochlorid  and  renaglandin 
in  distilled  extract  of  witch  hazel,  containing,  in  addition,  the  sul- 
phates of  sodium  and  ammonium  (Coblentz:  "The  Newer  Eemedies," 
4th  ed.,  12).  According  to  Heger  (Pharm.  Post.,  J^2,  373),  anasstiform 
is  a  solution  of  renaglandin,  cocain  hydrochlorid,  and  sodium  sulphate 
in  albumin. 

Anaezol. — An  antiseptic  local  anesthetic  containing,  in  solution, 
thymol,  menthol,  alcohol,  benzoic  acid,  carbolic  acid,  oils  of  wintergreen 
and  eucalyptus,  glycerin,  boric  acid,  indigo,  and  1  per  cent  cocain. 

Analgos  (Stephan). — A  dental  local  anesthetic  consisting  of  a  mix- 
ture of  thymol,  menthol,  phenol,  aspirin,  and  sodium  chlorid,  each  1  gm. 
with  0.5  of  cocain  hydrochlorid,  dissolved  in  95  gm.  of  diluted  alcohol. 

Andolin. — A  cocain-free  local  anesthetic.  See  Mayer,  Monatsh.  f. 
prakt.  Dermatol.,  1907,  J^5,  603.  It  is  said  to  consist  of  0.5  gm.  eucain 
B,  0.75  gm.  stovain,  0.008  gm.  suprarenin  hydrochlorid  and  physiological 


A    LIST    OF    ANESTHETICS  711 

salt  solution  to  make  100  gm.  Andolin  is  marketed  by  a  I'>erlin  eoiiceni, 
being  sold  in  sealed  tubes  containing  2  e.  c.  for  dental  practice.  See 
Pharm.  Ztg.,  53,  161. 

Anesin  or  Aneson. — An  aqueous  solution  of  1  per  cent  9,eetone- 
chloroform  (see  Chloretone  and  Methaform)  ;  a  local  anesthetic,  and  also 
substitute  for  cocain  in  infiltration  anesthesia  and  in  Oberst's  regionary 
anesthesia. 

On  the  chemistry  of  Anesin,  see  Cohn :  Pharm.  Zentralhalle,  JfO,  33 ; 
and  Vamossy:    Apoth.-Ztg.,  12,  608. 

On  the  application  of  Aneson,  see  the  following  contributions : 

Vamossy:  Ungar.  med.  Presse,  1897,  No.  21;  Deut.  med.  Woch., 
1897,  No.  36. 

Sternberg:    Klin.-therapeut.  Wocli.,  1898,  No.  39,  1398. 

Eubinstein :    Med.-Ztg.,  1898,  No.  33. 

Hanzel:     Wien.  Min.  Woch.,  1898,  1123. 

Mosbacher:    Munch,  med.  Woch.,  1899,  No.  3,  81. 

Impens :     Arch,  intern,  de  Pharmacodymie,  1901,  8,  77. 

Anesthaine. — This  is  a  local  anesthetic,  "each  fluid  ounce  of  which 
contains  5  gm.  of  stovain  with  synergistic  antiseptics  in  a  sterile  and 
ready-to-use  solution." 

Anesthia. — See  Ancesthesin. 

Anesthesin  Sulphophenate,  or  Sulphophenalylate  or  Sulphocarbo- 
late. — See  Subcutin. 

Anesthol  (Meyer). — See  Ancesthol  (W.  Meyer). 

Anesthol  (Weidig). — See  Ancesthol  (W.Meyer). 

Anesthone-Creme. — Adrenalin  hydrochlorid,  1 :  20,000 ;  paramido- 
ethyl  benzoate,  10  per  cent,  with  a  salve  (bland  oleaginous)  base. 

Anesthone-tape. — Gauze  which  has  been  treated  with  a  solution  of 
adrenalin  hydrochlorid  (1:20,000)  and  5  per  cent  of  paramido-ethyl 
benzoate. 

Anestile  (Ariesthyl). — A  local  anesthetic  containing  methyl  chlorid, 
1  part,  and  ethyl  chlorid,  5  parts.  This  preparation,  formerly  known 
as  an'estyle-bengue,  is  a  mixture  of  ethyl  and  methyl  chlorids.  See  Z. 
angew.  Chem.,  1901,  261. 

Anestol. — This  is  an  anesthetic  balm  intended  for  local  application 
in  neuralgia,  headache,  etc.  It  is  said  to  consist  essentially  of  menthol 
and  methylsalicylate  in  a  readily  penetrating  ointment  base. 

Anestyle. — See  Ancesthol. 

Anestyle-bengue.^See  Anestile. 

Anodyne. — See  Ethyl  Chlorid. 

Anodynone.— -This  is  a  trade  name  for  Ethyl  Chlorid  (q.  v.). 

Antemesin. — This  is  a  fanciful  designation  for  capsules  containing 
1-1.2  grs.  of  anesthesin  {q.  v.) ;  it  is  used  as  an  anodyne  in  gastric  ul- 
cer, dyspepsia,  etc. 


712  ANESTHESIA 

Antidolorin. — A  "purified"  ethyl  chlorid,  used  as  a  local  as  well  as  an 
inhalation  anesthetic. 

Antipyrin  (Dimethyloxyquinizin) . — To  quote  Heineck  ("General 
and  Local  Anesthesia,"  1900,  79)  :  "Antipyrin  is  valuable  to  obtain  an- 
esthesia of  the  urinary  bladder.  Its  anesthetic  power  is  less  than  that 
of  cocain,  but  it  has  the  advantage  of  being  less  toxic." 

Using  as  a  test  object  one  of  the  lower  legs  of  a  frog  immersed  in 
5  c.  c.  of  the  solution  to  be  tested,  and  determining  the  concentration 
necessary  to  produce  complete  numbness  in  30  minutes,  Bela  von  Isse- 
kutz  (Arch.  ges.  Physiol.,  lJf5,  448)  found  that  2.5  per  cent  cocain,  3,2 
per  cent  eucain-B,  6  per  cent  novocain,  and  5  per  cent  antipyrin  pro- 
duced numbness.  Employed  together,  antipyrin  increased  the  action  of 
cocain  46  per  cent,  of  eucain-B  39  per  cent,  and  of  novocain  19  per 
cent. 

The  employment  of  antipyrin  as  a  local  anesthetic  has  been  dis- 
cussed in  the  following  reports: 

Brick:  "De  Faction  calmante  de  I'antipyrin  chez  les  prostatiques," 
Semaine  med.,  1894,  128. 

Heinze:  "Experimentelle  Untersuchungen  liber  Infiltrationsanas- 
thesie,"  Virchows  Archiv,  1898,  153. 

Kocher:  (Antipyrin-cocain  solutions)  "Operationslehre,"  4th  ed., 
202. 

Lydston:  "Antipyrin  as  a  Local  Anesthetic,"  J.  of  Cutaneous  and 
Genito-urinary  Diseases,  May,  1898. 

Pousson:  "Analgesic  vesicale  par  I'antipyrin,"  J.  de  Med.  de  Bor- 
deaux, May  19,  1895. 

Vigneron:  "Analgesic  vesicale  par  I'antipyrin,"  Ann.  des  Maladies 
des  Org.  genito-urin.,  1894,  348. 

Antivom. — Anesthesin  tablets,  used  in  nervous  dyspepsia,  seasick- 
ness, etc.,  and  in  chloroform  narcosis. 

Apinol  (Apinolum). — Apinol  is  a  product  obtained  in  the  destruc- 
tive distillation  of  the  wood  of  pinus  palustris  and  pinus  australis.  It 
is  claimed  to  consist  mainly  of  Isevomenthon,  C^JIj^gO. 

Apinol  is  obtained  from  the  products  of  destructive  distillation  of 
pine  wood.  After  the  removal  of  turpentine  and  other  low  boiling  con- 
stituents by  distillation,  the  portion  boiling  between  +  182.2°-193.3° 
C.   (360°-380°  F.)   is  collected  and  purified. 

It  is  a  clear  amber-colored  oil  with  an  odor  resembling  that  of  the 
pine,  having  a  specific  gravity  of  0.946  and  an  approximate  boiling  point 
of  +  182.2°  C.  (360°  F.).    It  is  neutral  in  reaction. 

Actions  and  Uses. — Apinol  is  said  to  be  an  antiseptic,  local  anes- 
thetic, and  expectorant. 

It  is  said  to  be  useful  when  applied  externally  to  wounds,  burns,  ul- 


A   LIST    OF    ANESTHETICS  713 

cers,  and  denuded  surfaces  for  the  relief  of  pain  and  promotion  of 
healing. 

Apotheker  Maier's  Radikal-Anasthetikum. — See  Eadikal-A'nllslheii- 
Tcum. 

Arabic  Acid  Salts  with  Anesthetic  Bases. — Erhardt,  in  German 
Patent  of  May  32,  1908,  No.  211,800,  claims  a  process  for  manufacturing 
salts  of  arable  acid  with  anesthetic  bases,  consisting  in  acting  with  pure 
arable  acid  on  cocain,  tropacocain,  stovain,  novocain,  and  analogous 
compounds. 

Erhardt  {Arch.  Intern.  Pharmacodyn.,  21,  237)  stated  that  the 
arabinates  of  cocain  produced  fewer  toxic  symptoms  than  the  chlorids. 
The  arabinate  anesthesia  lasts  two  to  four  times  longer  than  that  due 
to  chlorids;  the  mucilaginous  elements  of  the  arabinates  render  the 
anesthetizing  bases  less  irritant,  and,  according  to  Erhardt,  a  higher 
grade  of  anesthesia  can  be  produced  than  with  the  chlorids. 

Aran's  Anaesthetic  Ether. — See  /Ether  Ancestheticus  Aranii. 

Arnold's  Dental  Anodyne  or  Local  Anaesthetic. — Acetic  acid  is  neu- 
tralized with  ammonium  carbonate,  and  the  mixture  is  saturated  with 
salicylic  acid.  The  wJiole  is  then  filtered  and  treated  with  cocain  hy- 
drochlorid  (Eng.  Pat.,  1887,  No.  7061). 

Barker's  Anesthetic. — Arthur  E.  Barker,  of  London,  recommended 
the  following  formula  for  the  anesthetic  solution  in  infiltration  anes- 
thesia : 

Eucain,  1  part  by  weight;  sodium  chlorid;,  8  parts  by  weight;  water, 
1,000  parts  by  weight. 

Heineck's  "General  and  Local  Angesthetics,"  1900,  115. 

Benesol. — A  local  anesthetic  used  in  dental  surgery  and  containing 
eucain-B,  cocain  hydrochlorid,  phenol,  menthol,  eucalyptol,  and  amyl 
nitrite,  in  solution  in  sterilized  distilled  water.  On  this  local  dental 
anesthetic,  see  Heger:    Pliarm.  Post,  Jf-3,  373. 

Bengue's  Mentholdragees. — These  are  said  to  contain  menthol  and 
sodium  borate,  with  0.001  gm.  cocain. 

Benzcain. — Guaiacol  benzoate,  or  benzyl  ester ;  a  local  anesthetic. 

Benzene  (Benzol). — John  Snow,  in  1818,  found  that  benzene  is  an 
indifferent  anesthetic  with  severe  after-effects.  Simpson  (1818)  found 
that  benzol  is  capable  of  producing  anesthesia  by  inhalation,  but  "ring- 
ing and  noises  in  the  head  are  excessive."  It  was  also  tried  by  T.  JSTun- 
neley  in  1849. 

The  inhalation  of  benzol  vapor  was  found  to  produce  narcotic  ef- 
fects, but  with  some  symptoms  indicative  of  a  noxious  action  on  the 
brain  and  spinal  cord  (Stone:  Med.  Gaz.,  1848,  J/.!,  1077).  It  may  be 
mentioned  that  liquid  benzol  is  said  to  act  as  a  narcotic  ("Anilin  und 
Anilinfarben/'   1864,    13).     Eichardson    (Sci.   Am.   SuppL,    No.    515, 


714  ANESTHESIA 

Nov.  14,  1885,  8227)  reported  that  benzol  vapor  is  heavy  and  disagree- 
able to  breathe;  that  the  action  is  determinate,  but  slow;  and  that  the 
anesthetic  value  is  very  indifferent,  and  the  after-effects  severe  and 
prolonged.  Benzene  is  said  to  produce  slight  paresis  of  the  voluntary 
muscles,  but  its  principal  action  is  on  the  higher  cerebral  centers,  pro- 
ducing lethargy  and  somnolence.  Later  a  kind  of  "intention  tremor" 
occurs  in  the  voluntary  muscles.  Naphthalene  is  less  toxic  than  benzene, 
and  pyrrol,  furfurane,  and  thiophene  resemble  benzene  to  a  certain  ex- 
tent in  their  physiological  action. 

On  the  influence  of  benzene  on  the  organism,  see  Arch.  Hygiene, 
1911,  75,  1-119.  "Benzine"  is  less  toxic  than  benzene.  See  Carbon 
Tetraclilorid. 

Benzenoform. — See  Carbon  Tetrachlorid. 

Benzineroid. — See  Carbon  Tetrachlorid. 

Benzinoform. — See  Carbon  Tetrachlorid. 

Benzoylamincethanol. — The  hydrochlorid  forms  long,  slightly  solu- 
ble needles,  melting  at  +  125°  C.     It  possesses  anesthetic  properties. 

Benzoyl-beta-hydroxy-tetrametliyl-pyrrolidiii. 

CH, 
CH, C CHj 

NH 
CHs C CH.Q.COCeHj 

CHj, 

This  has,  it  is  said,  a  powerful  local  anesthetic  action;  it  is  also  said  to 
be  less  toxic  than  beta-eucain  (Francis  and  Fortescue-Brickdale :  "The 
Chemical  Basis  of  Pharmacology,"  1908,  309). 

Benzoyl-ethyl-dimethylaminopropanol-hydrochlorid. — See  Stovain. 

Benzol  Peroxid. — This  compound,  CgHg  —  CO.O2.CO  —  CgHg,  con- 
sists of  white  crystals  fusing  at  -|-  103.5°  C,  and  freely  soluble  in  alco- 
hol, ether  and  carbon  disulphid,  more  sparingly  in  water  and  fatty  oils. 
It  is  odorless  and  keeps  well. 

Loewenhart  (Therap.  Monatsh.,  1905,  No.  8,  426;  Bull,  de  Pharm 
du  Sud-Est,  1905,  No.  10,  569)  recommended  benzoyl  peroxid  as  a  use- 
ful antiseptic.    From  his  observations,  when  applied  locally  as  a  powder 
and  in  the  form  of  a  solution,  it  does  not  produce  symptoms  of  irrita- 
tion, but  causes  a  mild  anesthetic  effect. 

Benzoylpsendotropein. — See  Tropacocain. 

Benzoyl-triacetone-alkamin-carboxyl. 
A  local  anesthetic,  which  has  not,  to  our  knowledge,  been  marketed. 


A   LIST    OF    ANESTHETICS  715 

CH, 

Clia C CH2 

I  I  /O.COCbHs 

NH         C< 
I  I ^COOH 

CHs C CH2 

I 
CH« 

Benzoyl-tropein. — A  local  anesthetic.  It  is  described  as  a  soluble 
compound  in  silky  needles. 

Filehne  {Berl.  hlin.  Woch.,  1887,  7)  found  that  benzoyl-tropein  is 
a  powerful  local  anesthetic.  He  also  reported  that  other  benzoyl  com- 
pounds are  local  anesthetics.  According  to  Filehne,  benzoyl  methyl  tri- 
acetonalkamin  is  the  most  powerful,  benzoyl  quinin  is  next,  and  benzoyl 
morphin  is  the  least. 

Benzoyl  Vinyl  Diacetonalkamin. — See  Eucain-B. 

Benzyl-morphin. — See  Peronin. 

Beta-benzoyloxy-l)eta-3:4-niethylenedioxyphenyletliyldiniethylaniin. 
— This  compound  is  an  example  of  local  anesthetic  alkamin  ester  de- 
rived from  secondary  alcohols  and  containing  only  two  carbon  atoms 
between  the  acyl  and  amino  groups.  It  is  built  on  an  adrenin  skeleton, 
and  is  said  by  Jowett  and  Pyman  (Proc.  of  7th  Internat.  Cong,  of  Ap- 
plied Chem.,  Section  IVa,  1)  to  have  very  considerable  local  anesthetic 
action. 

Betacain. — See  Eucain-B. 

Beta-ethyletramethyldiaminoglycerin  Benzoyl  Monochlorid. — Said 
to  be  of  value  as  a  local  anesthetic. 

Beta-eucain. — See  Eucain-B. 

Beta-gamma-dibenaoyloxy-dimethyl-propylamin. — This  compound  is 
an  example  of  local  anesthetic  alkamin  ester  derived  from  secondary 
alcohols  and  containing  only  two  carbon  atoms  between  the  acyl  and 
amino  groups.  See  Jowett  and  Pyman:  Proc.  of  the  7th  Internat. 
Cong,  of  Appl.  Chem.,  Section  IVa,  1. 

BilLroth's  Mixture  A.  C.  E. — Alcohol,  1  part;  chloroform,  3  parts; 
and  ether,  1  part.  Mix.  See  Hewitt:  "Angesthetics  and  Their  Adminis- 
tration," 3rd  ed.,  467. 

According  to  Buxton  (p.  292),  Billroth's  mixture  may  be  considered 
an  alcohol-chloroform  mixture  of  20  per  cent  alcohol.  It  is  said  by  the 
same  authority  to  have  no  advantage  over  the  "1  in  10  mixture."  Ter- 
rier and  Peraire  ("Petit  manuel  d'anesthesie  chirurgical,"  1894, 
179-80)  give  the  following  formula:  Chloroform,  100  gm. ;  alcohol,  30 
gm. ;  and  ether,  30  gm.  "This  anesthetic  mixture  is  used  in  the  surgical 
clinics  at  Vienna  by  Billroth,  Albert,   Mosetig,   Moorhof,   etc."     The 


716  ANESTHESIA 

formula  given  by  Terrier  and  Peraire  was  communicated  to  Lermoyez, 
who  assisted  at  many  practical  anesthesias  in  Vienna,  by  Eiselberh,  the 
assistant  to  Billroth. 

Blue  Light. — E.  C.  Titus  has  reported  that  blue  light  possesses  anes- 
thetic properties.  In  his  experiments  he  employed  a  series  of  glass  rods 
about  1/8  inch  in  diameter,  placed  side  by  side  and  tied  together  to  form 
a  flexible  mat.  The  glass  used  was  cobalt  blue,  so  that  no  red  rays 
would  be  transmitted.  When  the  glass-rod  mat  was  placed  upon  the 
part  to  be  anesthetized,  and  a  tungsten  lamp  was  brought  thereover  as 
closely  as  possible,  in  about  twenty  minutes  the  part  became  insensitive, 
so  that  superficial  and  even  deep  incisions  were  not  felt. 

Bonain  or  Bonainsche  Mixture. — This  consists  of  equal  parts  of 
crystalline  menthol,  cocain  hydrochlorid,  and  pure  carbolic  acid,  with 
or  without  1  per  cent  adrenalin. 

Boro-chloretone. — A  mixture  of  boric  acid,  3  parts,  and  chloretone,  1 
part,  used  as  an  antiseptic  anesthetic,  especially  as  a  dusting  powder  in 
painful  wounds. 

Borsain. — This  anesthetic,  according  to  Rabow  (Chem.-Ztg.,  1912, 
ISTo.  23,  206),  consists  of  pure  carbolic  acid,  menthol,  and  cocain  hydro- 
chlorid, aa.    On  its  use,  see  Mource:    La  clinique,  1911,  No.  6. 

Brandwundenol. — A  colorless  and  odorless  oil  with  an  addition  of  co- 
cain or  eucain. 

Braun's  Solutions  for  Anesthesia. — I.  Cocain  hydrochlorid,  0.1; 
physiological  salt  solution,  100.0;  1  per  cent  suprarenin  solution,  5 
drops.  II.  Cocain  hydrochlorid,  0.1;  physiological  salt  solution,  50.0; 
1  per  cent  suprarenin  solution,  5  drops.  III.  Cocain  hydrochlorid,  0.05 ; 
physiological  salt  solution,  10.0;  1  per  cent  suprarenin  solution,  10 
drops.  IV.  Cocain  hydrochlorid,  0.05;  physiological  salt  solution,  5.0; 
1  per  cent  suprarenin  solution,  10  drops. 

Braun's  Suprarenin  Tablets. — These  contain  0.00013  gm.  suprarenin 
borate,  0.01  gm.  cocain  hydrochlorid,  and  0.009  gm.  sodium  chlorid. 
They  are  used  for  the  production  of  local  anesthesia,  particularly  in 
dental  surgery. 

Brenzcain. — Pyrocatechin-methyl-benzyl  ester,  or  guaiacolbenzyl  es- 
ter, 

r  TT  /OCH3 
^^•XOCHo.CeHs, 
forms  colorless  crystals,  soluble  in  alcohol,  ether,  and  vasogen,  and  fus- 
ing at  4-  62°  C. 

The  irritant  action  of  guaiacol  on  the  mucous  membranes  suggested 
the  desirability  of  the  existence  of  a  preparation  which  might  possess 
all  the  advantagepus  properties  of  guaiacol  without  its  disadvantages. 
Brenzcain  seemed  to  satisfy  this  requirement,  and  was  accordingly 
used  by  Marcus  for  the  induction  of  local  anesthesia  by  means  of  cata- 


A   LIST    OF   ANESTHETICS  717 

phoresis  (Dent.  nied.  Woch.,  1897,  ISTo.  10;  Bericht  ilber  die  Verhand- 
lung  des  C entral-V ereins  Deutscher  Zaimdrzte,  1897,  409). 

See  Cocain  Tlydriodid. 

Brenz  (Pyro)  Catechin  Methyl -benzyl  Ether. — See  Brenzcain. 

Bromal. — Tribromacetaldehyd  hydratetl,  CBr3.GH(0H)2,  causes  ir- 
ritation of  the  respiratory  passages  in  animals ;  larger  doses  produce  dysp- 
nea and  cyanosis;  still  larger  doses  cause  anesthesia,  but  not  hypnosis. 

On  the  anesthetic  properties  of  Bromal,  see  Steinauer:  Virchow's 
Archiv  f.  path.  Anat.  u.  Phys.,  May  19,  1870. 

Bromic  Ether. — See  Ethyl  Bromid. 

Bromoform  (Tri-bromo-methane;  Formyl  tribromid). — When  pure 
this  compound  is  a  colorless  liquid  solidifying  at  -|-  8°  C.  and  boiling 
with  slight  decomposition  under  ordinary  pressure  at  -|-  151°  C.  It 
possesses  a  specific  gravity  of  2.902  at  -j-  15°  C,  but  with  1  per  cent  of 
ethyl  alcohol  present  the  density  is  2.885  at  -)-  15°  C.  The  ordinary 
preparation  deteriorates  rapidly. 

Bromoform  of  the  Deutsches  Arzneihuch  V.  contains  4  per  cent  alco- 
hol, and  has  the  density  2.829-2.833.  It  boils  at  +  148-150°  C, 
and  has  a  solidification  point  of  -|-  5-6°  C.  Feist  and  Garner  (Arch. 
Pharm.,  21^9,  458)  made  experiments  with  bromoform  carefully  purified, 
and  bromoform  to  which  was  added  4  per  cent  ethyl  alcohol ;  they  found 
the  density  to  be  2.6354,  the  boiling  point  to  be  -|-  146.25°  C,  and  the 
solidification  point  to  be  -)-  4°  C. 

As  early  as  1849  ISTunneley  and  Schuchard  proposed  bromoform  as  a 
general  anesthetic.  The  later  experiences  of  anesthetists  have  shown, 
however,  that,  although  bromoform  produces  a  rapid  narcosis  when  in- 
haled, its  use  is  attended  with  great  danger.  On  bromoform  poisoning, 
consult  Gerson:  Aerztl.  8achverst.-Ztg.,  1910;  Zentr.  f.  d.  ges.  Therap., 
1910,  447. 

Brucin. — Brucin  in  5  per  cent  solution  was,  at  one  time,  employed  as 
a  local  anesthetic,  but  it  was  abandoned  because  it  did  not  give  uniform 
results;  it  was  not  readily  absorbed,  and  had  none  of  the  advantages  of 
cocain.      See   Heineck :     "General   and   Local   Anesthetics,"    1900,    78. 

On  the  physiological  action  of  brucin,  see  Mays:  Therap.  Gaz., 
June,  1885.  On  the  employment  of  a  5  per  cent  solution  of  brucin  for 
the  production  of  local  anesthesia,  see  Therap.  Gaz.,  1886,  173. 

Blinte  and  Moral's  Local  Anesthetic. — Biinte  and  Moral  (Deut. 
Monats.  f.  Zalmheilk.,  1910,  No.  2)  proposed  the  two  following  solu- 
tions for  local  anesthesia  in  dental  practice: 


Novocain 

ad 

I 
1.50 

II 
0.50 

Sodium  Chlorid    . .  . 

0.92 

0.92 

Thymol 

0.02 

0.02 

Distilled  water 

100.00 

100.00 

718  ANESTHESIA 

Solution  I  is  for  adults  and  solution  II  for  children.  One  drop  of 
suprarenin  (1: 1,000)  should  be  added  to  each  c.  c.  before  use. 

Butyl-chloral  Hydrate  (Trichlorbutylidene  glycol). — Proposed  by 
Liebreich  in  1870  as  a  remedy  for  trigeminal  neuralgia.  In  medicinal 
doses  it  produces  deep  sleep  with  cranial  analgesia. 

Butyl  Chlorid. — This  compound  was  introduced  as  an  anesthetic  by 
B.  W.  Eichardson  in  1869.  He  reported  {Sci.  Am.  Suppl.,  ISTo.  515, 
8227)  that  its  physiological  properties  are  practically  identical  with 
those  of  amyl  chlorid  {q.  v.),  and  that  its  anesthetic  value  is  practically 
the  same  as  for  amyl  chlorid.  The  committee  of  the  British  Medical 
Association  stated  that,  when  butyl  chlorid  was  administered  to  rabbits, 
it  affected  respiration,  although  not  very  rapidly. 

Butyl  Hydrid. — This  compound,  introduced  by  B.  W.  Eichardson  in 
1867,  was  found  by  him  to  have  the  same  physiological  properties  as 
amyl  hydrid  (g.  v.),  but  the  action  was  more  rapidly  developed.  As  re- 
gards its  anesthetic  value,  this  was  found  to  be  the  same  as  for  amyl 
hydrid,  but,  being  a  gas,  it  was  found  to  be  less  practical  for  adminis- 
tration (see  Eichardson:  Sci.  Am.  Suppl.,  Nov.  14,  1885,  No.  515, 
8227). 

Calcium  Guaiacol  Sulphonate. — See  Guaiacyl. 

Camphor  Phenylated  (Camphora  carbolisata;  Phenol  Camphor). — A 
local  anesthetic,  used  chiefly  in  dental  practice. 

For  the  physical  properties  of  phenol  camphor,  consult  Lemberger, 
Therapie  die  Gegenwart,  1906,  No.  5;  Przeglad  lekarshi,  1906,  No.  23; 
and  Pliarm.  Ztg.,  1906,  No.  38. 

Camphorated  Salol. — See  Salol  Camphor. 

Canadol. — A  very  light  petroleum  ether  ("light  ligroin")  of  the  spe- 
cific gravity  0.650-0.700 ;  a  local  anesthetic  used  by  spraying. 

Caprylic  Hydrid. — The  experiments  of  Eichardson  upon  animals 
showed  that  this  compound  produced  a  long  period  of  preliminary  ex- 
citement, accompanied  by  vomiting.  Anesthesia  thus  induced  was  very 
evanescent. 

Carbolic  Acid. — Phenol  has  found  use  as  a  local  anesthetic.  Like 
creosote,  phenol  is  popularly  employed  to  inhibit  toothache;  indeed,  it 
seems  that  all  phenols  containing  at,  least  one  free  hydroxyl  group  are 
anesthetic.  However,  their  use  is  very  limited,  owing  to  their  caustic 
action.    Moreover,  carbolic  acid  does  not  penetrate  deeply. 

Barwell  {Archiv.  Internal,  de  Laryng.,  1907,  No.  3)  described  a  so- 
lution containing  carbolic  acid,  10  parts  by  weight;  lactic  acid,  50  parts 
by  weight;  and  formaldehyd,  7  parts  by  weight,  for  the  treatment  of 
tuberculous  laryngitis.  It  was  said  to  have  an  anesthetic  as  well  as  a 
curative  efl'ect. 

On  carbolic  acid  as  a  local  anesthetic,  consult  the  following  contri- 
butions : 


A   LIST    OF    ANESTHETICS  719 

Bericht  d.  K.  K.  Kranlcenansialt  Rudolphstiftung  in  Wien,  187G, 
293. 

Bill:    Am.  J.  Med.  Scl.,  Oct.,  1870. 

Caspar!:    Z.  klin.  Med.,  1883,  537. 

Pirri:    Lancet,  Sept.  19,  18G7. 

Eae:    Am.  J.  Med.  Sci.,  1870,  573. 

Eichardson :     Deut.  med.  Woch.,  1891,  1161.  • 

Smith :    Med.  Rec,  1872. 

Walser:  Mitteilungen  des  Vereins  der  Arzte  SteiermarJcs,  189G, 
No.  4. 

Van  der  Weyde :    Phila.  Med.  Surg.  Rec,  Aug.,  1868. 
Carbon  Dioxid. — A  mixture  of  limestone  and  vinegar  was  used  by  the 
Romans  as  a  local  anesthetic  (Pliny)  ;  Hickman  proposed,  in  1828,  that 
it  be  used  for  inhalation   (for  a  full  account  of  Hickman's  work,  see 
pp.  5-7) ;  and  it  was  used  by  Snow  in  1848. 

B.  W.  Eichardson  used  carbon  dioxid  as  an  anesthetic  in  1852,  and 
it  had  been  also  tried  by  ISTunneley  three  years  earlier.  Eichardson 
(Sci.  Am.  Suppl.,  No.  515,  8227)  found  that  air  containing  25  per  cent 
of  carbon  dioxid  produced  rapid  insensibility;  that  the  insensibility  was 
deep,  with  convulsive  action,  asphyxia,  and  reduction  of  temperature. 
He  pointed  out  that  its  anesthetic  action  had  not  been  investigated  fully, 
but  that  death  probably  resulted  from  asphyxia,  with  the  respiration 
failing  primarily  and  the  muscular  irritability  becoming  rapidly  ex- 
hausted; the  after-effects  of  recovery  were  stated  to  be  neither  very  pro- 
longed nor  severe  from  deep  anesthesia.  Ozanam  used  a  mixture  of  75 
parts  of  carbon  dioxid  with  25  parts  of  air  in  an  operation  upon  a  young 
man  for  the  removal  of  an  abscess. 

Malan  (Gazzetta  degli  espedali  e  delle  cUniche,  1910,  No.  105)  used 
solid  carbon  dioxid  to  produce  anesthesia  by  cold;  he  found  the  anes- 
thesia ■  sufficient  and  deeper  than  that  produced  by  ethyl  chlorid. 
Gottheil  (/.  Surg.,  22,  7;  N.  Y.  Med.  J.,  July  3,  1909)  used  solid  car- 
bon dioxid  as  an  anesthetic  cauterant.    See  also : 

Serano-Nouell :    Monatsli.  f.  praJct.  Dermatol.,  50,  No.  7. 

Pusey :    Monatsli.  f.  praht.  Dermatol.,  51,  No.  7. 

Macleod :    Brit.  Med.  J.,  1910,  No.  2561,  254. 

Fabry  and  Zweig:    Miinch.  med.  Woch.,  1910,  No.  13. 

Klotz:    Berl.  klin.  Woch.,  1910,  No.  48. 

On  the  inhalation  of  a  mixture  of  carbon  dioxid  and  oxygen  as  an 
auxiliary  to  chloroform  anesthesia,  see  Levi:  Rivista  critica  di  clinica 
medica,  1910,  465;  Crescenzi:  Klin.-tlierap.  Woch.,  1910,  No.  40,  960; 
Marchetti :    Ibid.,  961. 

Carbon  Disulphid. — Although  Nunneley  introduced  carbon  disulphid 
for  complete  anesthesia  in  1849,  it  has  only  found  employment  as  a  local 
anesthetic.     Simpson  found  carbon  disulphid  to  be  a  rapid  and  powerful 


720  ANESTHESIA 

anesthetic,  but  disadvantageous.     It  was  also  tried  by  Harold  Thanlow 
in  1850,  B.  W.  Richardson  in  18G8,  Hermann,  Miller,  Serre,  and  others. 

On  the  physiological  action  of  carbon  disulphid,  see  the  following: 

Delpech:  "Memoire  sur  les  accidents  que  developpe  chez  les 
ouvrieres  en  caoutchouc  du  sulfure  de  carbone  en  vapeur,"  Paris,  1865. 
For  a  discussion  of  the  investigations  of  Delpech,  see  Chem.  News,  1863, 
216;  Bernhardt:  Ber.  Idin.  Woch.,  1866,  No.  32;  Husemann: 
Jahresher.,  1872,  495;  Yermorel:  "Le  sulfure  de  carbone,  ses  proprie- 
tes,  sa  fabrication,  moyens  pratiques  de  verifier  sa  purite,'^  Tours,  1886. 

Richardson  (Sci.  Am.  Suppl.,  No.  515,  Nov.  14,  1885,  8227)  re- 
ported that,  when  perfectly  pure,  carbon  disulphid  is  of  a  pleasant 
ethereal  odor,  and  free  from  pungency;  that  the  quantity  required  for 
anesthesia  was  4  to  8  fluid  drachms;  that  the  quantity  of  vapor  in  air 
was  10  per  cent ;  that  anesthesia  Avas  very  rapid,  being  produced  in  from 
three  to  five  minutes  with  a  brief  spasmodic  stage;  that  recovery  was 
rapid  and  complete,  with  few  bad  effects;  and  that  the  reduction  of 
body  temperature  under  deep  anesthesia  was  2°  F.  He  stated  then 
(1885)  that  its  anesthetic  value  was  yet  undetermined,  but  that  from 
experiments  on  inferior  animals  it  seemed  to  be  safe.  To  quote  Rich- 
ardson, "Death  in  the  vapor  is  gradual,  the  circulation  outliving  the 
respiration.  In  one  animal,  a  dog,  author  observed  life  return,  spon- 
taneously, after  respiration  had  ceased  for  seven  minutes." 

Workmen  in  caoutchouc  factories,  wherein  carbon  disulphid  is  em- 
ployed as  a  solvent,  sometimes  develop  toxic  phenomena,  as  headache, 
giddiness,  deafness,  amaurosis,  and  occasionally  paraplegia.  It  would 
seem  to  be  demonstrated  that  carbon  disulphid  is  a  powerful  poison,  the 
direct  action  being  narcotic. 

It  may  be  mentioned  here  that  the  xanthates  have  a  similar  action  to 
carbon  disulphid,  and  it  is  said  that  a  general  narcosis  can  be  effected 
in  man  by  them;  this  is  as  one  would  expect  since  the  xanthates  arc 
readily  decomposed  into  alcohol  and  carbon  disulphid. 

Carbon  Monoxid. — Nunneley  proposed  carbon  monoxid  as  an  anes- 
thetic in  1849.  Snow,  Herapath,  and  Richardson  experimented  with 
it  in  1852.  Although  dangerous  to  the  human  economy,  it  was  used  on 
lower  animals  by  Richardson.  He  reported  that  5  per  cent  of  carbon 
monoxid  in  air  caused  rapid  anesthesia,  with  convulsive  action,  and  a 
fall  of  temperature  at  2°  F.  under  deep  narcotism.  The  gas  is  a  cumula- 
tive poison. 

Carbon  Tetrachlorid. — A.  Sansom  and  Protheroe  Smith  {B.  and  F. 
Med.  Chir.  Rev.,  1867,  551)  introduced  "chloro-carbon"  for  inhalation 
in  1867;  however,  it  has  been  but  little  used  for  this  purpose,  although 
it  has  been  employed  as  a  local  anesthetic. 

Richardson  (Sci.  Am.  Suppl.,  No.  515,  8227)  stated  that  the  quan- 
tity of  carbon  tetrachlorid  required  for  complete  anesthesia  was  4  to  8 


A   LIST    OF   ANESTHETICS  721 

fluid  drachms;  that  the  required  change  of  air  by  vapor  was  5  to  10 
per  cent;  that  the  anesthesia  was  very  slow  and  prolonged  when  in- 
duced, and  that  the  convulsive  stage  was  long  and  acute.  He  reported 
that  its  anesthetic  value  was  indifferent,  the  action  being  too  slow  and 
the  recovery  too  prolonged;  the  temperature  was  found  to  be  reduced 
4°  F.  during  deep  anesthesia.  See,  also,  Simpson:  Med.  Times  and 
Gaz.,  Dec,  1865;  Lancet,  June,  1867. 

Carbon  tetrachlorid  is  said  to  act  much  more  slowly  and  persistently 
than  chloroform.  It  is  usually  stated  to  be  a  more  powerful  heart  de- 
pressant (Simpson,  loc.  cit.),  but  Cushny  describes  it  as  only  half  as 
powerful  as  chloroform.  Marshall  found  that  the  differences  in  action 
between  carbon  tetrachlorid  and  chloroform  were  mainly  due  to  its 
physical  characteristics.  It  is,  however,  more  toxic  and  more  irritating 
to  the  mucous  membrane  of  the  trachea  and  bronchi.  It  has  been  used 
by  hairdressers  to  clean  the  hair,  and  a  case  of  accidental  poisoning 
owiiig  to  the  inhalation  of  the  vapor  is  recorded  in  the  Lancet,  1907,  1, 
1725 ;  this  case  very  nearly  had  a  fatal  termination.  There  is  record  of 
a  fatal  case  in  Paris. 

-'  According  to  the  investigations  of  Lehmann  {Chem.-Ztg.,  1906,  No. 
29,  330),  the  anesthetic  action  of  benzin  (see  Benzene)  is  quantita- 
tively greater  than  that  of  carbon  tetrachlorid. 

On  the  physiological  action  of  carbon  tetrachlorid,  see  the  follow- 
ing: 

Andrews:     Chicago  Med.  Exam.,  Dec,  1867. 

Bianchini:     Stazione  Sperimentale  Agraria  Italiana,  1904,  171. 

Freyss:    CJiem.-Ztg.,  1903,  1137. 

Haller:    Bericht  iiber  die  Weltausstellung  im  Paris,  1900. 

Morel:     Compt.  rend.,  1877,  1460. 

Eegnauld:    Ihid.,  1885,  1146. 

Schwartz:  "Handbuch  zur  Erkennung,  Beurteilung  und  verhutung 
der  Feuers-  und  Explosionsgefahr  chemisch-technischer  Stoffe  und  Be- 
triebsanlagen,"  1902,  284. 

Caustica. — A,  White :  Arsenic  acid,  0.001,  morphin  hydrochlorid, 
0.0005;  and  cocain  hydrochlorid,  0.0005.  C,  Black:  Cobalt,  0.003; 
morphin  hydrochlorid,  0.0005;  and  cocain  hydrochlorid,  0.0005.  For 
application  in  teeth  cavities. 

C.  E.  Mixture. — An  anesthetic  mixture  of  2  parts  of  chloroform 
and  3  parts  of  ethyl  ether.  Schiifer  and  Scharlieb  (Travis.  Roy.  Soc. 
Edinburgh,  J^l,  ii,  No.  12)  have  shown  that  C,  E.  Mixture  is  based  upon 
the  wholly  fallacious  theory  that  alcohol  in  the  A.  C.  E.  Mixture  is 
merely  a  menstruum,  and  that  ethyl  ether  in  the  C.  E.  Mixture  exerts  a 
stimulating  action  on  the  circulation. 

Ceratum  Odontalgicum. — This  toothache  paste  is  composed  of  wax, 
chloral  hydrate,  camphor,  and  thymol ;  it  is  also  known  as  dontocerat. 


722  ANESTHESIA 

Chelen  or  Chelene.— A  "purified"  ethyl  chlorid.     See  Kelene. 

Chevanne's  Local  Anesthetic. — The  followicg  anesthetic  has  been 
proposeu  by  Chevanne  for  mucous  surfaces  without  cocain:  Phenol, 
30  gr. ;  menthol,  30  gr. ;  quinin  hydroehlorid,  24  gr. ;  and  adrenalin, 
l/12th  gr.  See  Pharm.  J.,  32,  820.  Chevanne  states  that  this  solution 
has  no  caustic  action  and  that  it  is  better  than  urea-quinin  solution 
(Klin.-tlierap.  Woch.,  1910,  Xo.  50,  1253;  Rev,  Hebd.  de  Laryng.,  1910, 
305). 

Chlorsethofonn. — Chloroform  containing  0.25  per  cent  of  ethyl  chlo- 
rid.   See  Chem.  and  Drug.,  1904,  1289. 

Chloral  (Chloral  Hydrate). — Forne  stated  that  the  administration  of 
chloral  hydrate  in  connection  with  the  inhalation  of  chloroform  pro- 
duced an  effect  upon  the  patient  which  very  closely  resembled  the  ef- 
fects produced  by  the  combined  use  of  morphin  and  chloroform.  In  a 
discussion  of  this  affirmation  before  the  Chirurgical  Society  of  Paris, 
Dolbeau  and  Demarquay  insisted  upon  the  dangers  attending  such  a 
combination.  Kappeler  made  trial  of  the  combination  of  chloral  hy- 
drate with  ether;  though  rather  less  disagreeable  than  the  association  of 
morphin  with  ether,  there  was  very  little  to  recommend  this  mode  of 
inducing  anesthesia.  On  a  case  of  death  from  the  effects  of  chloral  and 
ether,  see  Morton  and  Lewis:    Am.  J.  Med.  Sci.,  Oct.,  1876,  415. 

This  narcotic  may  produce  complete  surgical  anesthesia.  It  was 
used  intravenously  for  a  short  period  in  the  middle  of  the  last  century, 
and  major  operations  have  been  performed  under  its  influence.  The 
dosage  had,  however,  to  be  too  high  for  the  complete  safety  of  the  pa- 
tient. Chloral  hydrate  was  fo\md  by  Delbet  and  Dupont  (Rev.  de  Chir., 
June  10,  1910;  Klin.-therap.  Wocli.,  1910,  682)  to  possess  advantages 
over  even  scopolamin  for  commencing  chloroform  anesthesia.  They  re- 
ported on  850  cases  of  chloroform  anesthesia  in  which  chloral  hydrate 
was  employed. 

On  chloral  hydrate  as  a  veterinary  anesthetic,  see  Eehse:  Monatsh. 
f.  pralct.  Tierlieilk.,  21,  413;  Berl.  tierdrztl.  Woch.,  1911,  77. 

Chloral-acetone  Chloroform  (Chloran). — It  has  been  said  that  the 
use  of  acetone-chloroform  (see  Chloreione  and  Meihaform)  as  a  hyp- 
notic and  local  anesthetic  is  somewhat  limited,  owing  to  its  insolubility 
in  water,  dilute  alcohol,  and  its  burning  taste  (Coblentz:  "The  Newer 
Eemedies,"  4th  ed.,  33).  It  has  been  found  that  molecular  quantities 
of  chloral  hydrate  or  chloral  and  acetone-chloroform  condense,  affording 
a  compound  which  is  said  to  be  soluble  to  the  extent  of  1  per  cent  in  cold 
water,  very  soluble  in  weak  water-alcohol  solutions,  and  free  from  burn- 
ing taste.     The  combination  possesses  the  following  formula: 

^^^^^2^\0.CH(0H).CCL 
It  forms  fine  feathery  needles,  melting  at  -|-  65°  C,  and  having  a  cam- 


A   LIST    OF   ANESTHETICS  723 

phoraceous  odor.  It  is  said  to  be  a  prompt  hypnptic  and  to  have  local 
anesthetic  properties.  Chloral-acetone  chloroform  is  manufactured  by 
a  Swiss  firm. 

Chloralamid. — See  Chloralformamid. 

Chloralformamid.— This  compound,  CCl3CH(0H).C0NH2,  also 
known  as  "chloralamid"  and  "formamidated  chloral,"  is  said  to  be  an 
uninjurious  hypnotic  and  analgesic;  its  action  is  less  harmful  than  that 
of  chloral,  but  it  has  less  hypnotic  power.  Chloralformamid  forms  lus- 
trous, colorless  crystals,  melting  at  -f-  114-115°  C.  It  is  decomposed  at 
higher  temperatures  and  by  wajm  solvents.  It  slowly  dissolves  in  20 
parts  of  water,  and,  at  -|-  25°  C,  in  1.3  parts  of  alcohol. 

Chloralimid. — Trichlorethylidenimid,  CCI3.CH  :NH,  is  prepared 
from  chloral-ammonia  by  means  of  heat  or  from  hydrated  chloral  by 
ammonium  acetate.  It  forms  colorless  crystals  which  are  tasteless  and 
odorless;  it  possesses  a  melting  point  of  -|-  155°  C,  and  is  readily  solu- 
ble in  alcohol,  ethyl  ether,  chloroform,  and  oils,  but  is  only  sparingly 
soluble  in  water.  Chloralimid  is  employed  both  as  a  hypnotic  and  an 
analgesic. 

Chloral-menthol  (Mentholated  Chloral). — This  preparation  has  been 
used  as  a  local  anesthetic  in  facial  and  other  neuralgias. 

Chloral-orthoform. — Amido-oxybenzoic  esters  combined  with  chloral 
have  been  found  to  act  as  local  anesthetics  and  antiseptics. 

Chloral-orthoform  occurs  in  yellow  crusts,  sparingly  soluble  in  wa- 
ter, but  readily  soluble  in  warm  alcohol  and  in  ethyl  ether.  When  it 
is  warmed  with  diluted  inorganic  acids,  chloral  is  produced. 

Chloralose. — Chloralose  (Alphachloralose;  anhydroglucochloral) 
forms  colorless  crystals,  possessing  a  bitter,  disagreeable  taste,  and  hav- 
ing the  composition  CgH^iClgOe.  It  is  soluble  in  alcohol  and  in  200 
parts  of  water;  it  melts  at  -1-  185°  C.  Chloralose  is  known  chiefly  as 
a  hypnotic,  but  Kshishkovskii  (Zentr.  Physiol.,  25,  8)  found  that  when 
it  was  injected  intravenously  (0.07  per  kg.)  it  produced  in  ruminants, 
in  15  to  20  minutes,  a  deep  sleep,  which  lasted  from  5  to  6  hours,  with 
no  ill  effects.  The  anesthetic  action  was  especially  good  in  sheep  (5  ex- 
periments), but  not  so  satisfactory  in  rabbits  and  cats  (4  experiments). 
When  administered  per  os  or  per  rectum^  it  was  found  to  be  less  effec- 
tive. 

Chloramyl. — Chloroform,  one  pound,  mixed  with  2  drachms  of  amyl 
nitrite  (q.  v.). 

Chlorbutane. — This  compound  has  been  employed  for  producing  total 
anesthesia.     See  Butyl  Chlorid. 

Chlorbutanol. — See  Chloretone  and  Methaform. 

Chlorbutol. — A  synonym  for  Chloretone  (q.  v.). 

Chlorethyl. — See  Ethyl  Chlorid. 

Chlorethylidene. — See  Ethylidene  Chlorid. 


724  ANESTHESIA 

Chlorethylene  Chlorid. — See  Ethylene  {Monocliloro-cMorid), 

Chloreton  or  Chloretone  (Acetone  chloroform;  chlorbutanol ;  "Ane- 
son";  "Anesin"). — This  preparation  is  the  tertiary  trichlorbutyl  alcohol 
[110.0(0113)20013],  and  is  used  as  a  local  anesthetic  and  internal  hyp- 
notic. It  forms  white  acicular  crystals  possessing  a  taste  resembling 
that  of  camplior.  It  dissolves  sparingly  in  water,  but  more  freely  in  al- 
cohol and  glycerin.  Acetone  chloroform  was  discovered  in  1881  by 
Willgerodt,  and  its  solution  (see  Anesin)  is  said  to  produce  no  local  irri- 
tation and  no  toxic  symptoms.  Because  of  the  insolubility  of  chloretone 
in  ordinary  aqueous  liquids  or  exudates,  the  local  anesthetic  effect  de- 
velops very  slowly,  and  consequently  the  substance  cannot  be  compared 
with  cocain  hydrochlorid  for  rapidity  of  action.  The  manufacturers 
do  not  lay  any  stress  whatsoever  upon  the  effect  of  chloretone  as  a 
rapid-acting  local  anesthetic,  but  do  commend  it  very  highly  as  a  seda- 
tive and  hypnotic  (Kossa,  in  1893,  found  acetone-chloroform  to  have 
anesthetic  and  narcotic  properties),  and  also  for  its  power  of  preventing 
the  growth  of  bacteria  or  fungi.  A  practical  objection  to  the  use  of 
chloretone  is  that  the  toxic  and  therapeutic  doses  are  too  nearly  alike, 
but  it  may  be  employed  in  small  doses  to  produce  local  anesthesia. 

See  Anesin;  but  on  crystalline  acetone-chloroform,  a  1  per  cent  water 
solution  of  which  constitutes  anesin,  see  the  following : 

Willgerodt:  Ber.,  1881,  2455;  Willgerodt  and  Gemeser:  J.  praM. 
Chem.,  (2),  37,  362. 

Houghton  and  Albrich:    J.  Am.  Med.  Assn.,  1899,  77 

Lyon:    P/iarm.  J".,  1901,  No.  1609,  521. 

Cappelletti:    Riforma  medica,  1901,  ISTos.  277  and  278. 

Wheder:     Lancet,  1903,  No.  4148,  615. 

Fawcitt :    lUd.,  1903,  No.  4149,  687. 

Bickle:    Therap.  Gaz.,  Oct.,  1902. 

Wynter:    Lancet,  1907,  No.  4361,  879. 

Fiocre :    Presse  med.,  1907,  No.  58,  460. 

De  Boter:    Rev.  Barcelonesa  d.  enferm.  de  oido,  1907,  No.  9. 

Martinet:     Therap.  Monatsh.,.  1908,  115. 

Wargnier :    These  de  Lille,  1908. 

Leyden:    Med.  Klinik,  1910,  No.  52. 

Friedeberg:    Deut.  med.  Woch.,  1910,  9. 

Jenny-Berne :    Therapie  der  Gegenwart,  Aug.,  1911,  13,  No.  8. 

Welsh:     Lancet,  1911,  No.  4582. 

See  Methaform. 

Chloriden. — See  Ethylidene  Chlorid. 
Chlorocarbon.— See  Carbon  Tetrachlorid. 
Chloroform. — See  Ohapter  VII. 

Chloroform- Acetic  Acid. — Fournier   {Compt.  rend.,  53,  1066)  used 
a  mixture  of  chloroform  and  glacial  acetic  acid  as  a  local  anesthetic. 


A  LIST    OF   ANESTHETICS 


725 


Chloroform-Ether-Menthol. — This  spray  for  local  anesthesia  con- 
sists of  chloroform,  10  parts;  ethyl  ether,  15  parts;  and  menthol,  1  part. 
The  local  anesthesia  produced  thereby  is  said  to  last  from  two  to  six 
minutes. 

Chloroformium  Albuminatum. — See  Cldoroformium  Gelatinosum. 

Chloroformium  Colloidale. — See  Desalgin. 

Chloroformium  Gelatinosum. — Prepared  from  a  mixture  of  equal 
parts  of  fresh  albumen  and  chloroform;  used  for  applying  chloroform 
locally. 

Chloromethane. — See  Methyl  Chlorid. 

Chloryl  (Coryl). — A  local  anesthetic  mixture  consisting  of  methyl 
and  ethyl  chlorids;  it  is  said  to  be  milder  in  action  than  ethyl  chlorid. 
Chloryl  has  also  been  used  externally. 

Chloryl  Anesthetic. — An  "absolute  ethyl  chlorid"  of  Scottish  manu- 
facture. 

Cloran. — See  Chloral-Acetone  Choloroform. 

Cocadrenal. — A  sterilized  solution  of  adrenalin  hydrochlorid  and 
cocain,  used  as  a  local  anesthetic. 

Cocaethylin  (Ethyl-benzoylecgonin). — A  local  anesthetic,  like  cocain 
in  action,  but  milder. 

Cocain.- — The  constitution  of  benzoyl-ecgonin-methyl-ester  is  ex- 
pressed by  the  formula: 


CH.COOCH3 


CH.O(C6H6CO) 


CH2 


It  is  well  known  as  a  producer  of  local  anesthesia  (Schraff,  1862), 
which  is  by  far  its  most  important  physiological  attribute  from  a  prac- 
tical standpoint.  Not  only  pain  but  all  sensations  are  affected;  for  ex- 
ample, taste  is  abolished  upon  the  application  of  cocain'  to  the  mucous 
membrane  of  the  mouth,  and  heat  and  cold  are  not  felt.  This  local 
anesthetic  action  appears  to  be  dependent  upon  the  structure  of  the 
ecgonin  nucleus,  and  upon  the  presence  and  relative  positions  of  the 
two  substituting  groups,  the  alkyl  and  benzoyl  radicals.  Of  these  fac- 
tors, the  presence  of  the  benzoyl  group  seems  to  be  the  most  important. 
The  anesthetic  property  of  cocain  has  been  shown  to  be  associated  with 
its  functions  as  an  alkalamin  ester. 

For  an  investigation  of  its  recommended  substitutes,  see,  among 
others,  Le  Brocq:  Pharm.  J.,  82,  673;  Brit.  Med.  J.,  Mar.  27,  1909, 
783.     On  the  results  of  a  clinical  study  of  cocain,  stovain,  tropacocain, 


726  ANESTHESIA 

novocain,  eucain,  etc.  {q.  v.),  see  Piqnand  and  Dreyfus:  J.  physiol.  path. 
gen.,  12,  70.  On  the  comparative  toxicity  and  pharmacological  action 
of  cocain,  stovain,  anesthesin,  novocain,  alypin,  and  eucain-B,  as  de- 
termined by  Chevalier  and  his  students,  see  Bull.  sci.  pliarmacolog.,  16, 
518;  cf.  also  Senator:    Milnch.  med.  ^Yoch.,  1910,  ISTo.  10,  524. 

On  the  distinction  between  cocain  and  its  substitutes,  see  Scher- 
batschev:   Apoth.-Ztg.,  21,  441. 

For  a  report  of  an  investigation  relating  to  combinations  of  cocain 
with  other  local  anesthetics,  see  Leo  Zorn:  Z.  f.  exper.  Path.  u.  Therap., 
12,  529. 

Cocain-Alinninum  Citrate. — This  product  of  a  patented  process  is 
employed  as  an  astringent  and  local  anesthetic;  it  is  a  compound  of  1 
molecule  of  aluminum  citrate  with  1  molecule  of  cocain. 

Cocain  and  Adrenalin  Ointment. — An  ointment  said  to  contain  co- 
cain hydrochlorid,  2  per  cent;  solution  of  adrenalin  chlorid,  17  per 
cent;  hydrous  wool  fat,  25  per  cent;  white  petrolatum  sufficient 
to  make  100  per  cent.  Put  up  in  collapsible  tubes  for  application  to 
the  eye. 

Cocain  Arabinate. — This  salt  was  introduced  by  Erhardt  as  a  suc- 
cedaneum  for  the  hydrochlorid,  especially  for  lumbar  anesthesia.  It  is 
said  to  be  absorbed  much  more  slowly  and  it  is  reported  that  its  anes- 
thetic effect  lasts  three  times  as  long  as  that  of  the  hydrochlorid;  more- 
over it  has  been  recorded  that  it  scarcely  disturbs  the  nervous  system. 

Cocain-Ethyl  (or  Methyl)  Chlorid.— In  Eng.  Pat.  10,594,  1897,  the 
claim  is  made  for  the  production  of  local  anesthetics  by  means  of  solu- 
tions of  cocain  in  liquids  boiling  below  -|-  30°  C. 

Cocain  Benzoate;  Cocain  Borate;  Cocain  Formate. — Employed  as 
local  anesthetics.  Cocain  borate  (68.7  per  cent  cocain)  solutions  are 
more  permanent  than  those  of  the  hydrochlorid. 

Cocain  Hydriodid. — Marcus  (Ber.  Hher  Verhandlung  Central-Ver- 
eins.  Deut.  Zahndrzte,  1897,  409)  proposed  the  employment  of  "cocainse 
hydroiodidas"  in  dental  surgery  as  a  substitute  for  cocain  hydrochlorid 
as  a  means  of  producing  electro-anesthesia.  See,  also,  Mewes:  Elek- 
trochem.  Z.,  1897,  No.  3,  49. 

Cocain  Hydrobromid;  Cocain  Hydrochlorid. — Employed  as  local 
anesthetics. 

Cocain  Lactate. — A  dental  anesthetic.  It  is  a  thick,  white  liquid, 
soluble  in  water  and  alcohol. 

Cocain  Nitrate ;  Cocain  Oleate. — Employed  as  local  anesthetics.  Co- 
cain oleate  is  a  5,  10,  15,  25,  or  50  per  cent  solution  of  cocain  in  oleic 
acid,  soluble  in  alcohol  and  oils. 

Cocain  Phenate  (Phenol-Cocain;  Cocain  Carbolate;  Cocain  Pheny- 
late). — Veasey  {Med.  News,  1893,  345)  states  that  cocain  phenate  in  a  2 
per  cent  solution  in  alcohol  and  water  acts  excellently  as  a  local  anes- 


A   LIST    OF    ANESTHETICS 


727 


thetiCj  while  it  does  not  produce  the  unpleasant  secondary  effects  caused 
by  cocain  hydrochlorid.     It  also  possesses  an  antiseptic  action. 

Cocainum  Phenylicum  Merck-Oefele. — A  honey-yellow  mass  of  but- 
ter-like consistency  with  crystals  distributed  throughout;  it  is  insoluble 
in  water,  and  is  slightly  soluble  in  alcohol  and  ether.  It  possesses  the 
composition  0^71121^04. CeHjOH.  It  is  used  as  a  local  anesthetic  in 
dental  operations. 

Cocainum  Phenylicum  Poisnot. — A  mixture  of  2  parts  of  cocain,  1 
part  of  phenol,  20  parts  arachis  oil,  and  40  parts  paraffin  oil,  supplied 
in  1-gm.  tubes. 

Cocainum  Phenylicum  Vian. — A  mixture  of  phenol  with  cocain 
hydrochlorid. 

Cocain  Spray. — Oocain  hydrochlorid,  0.12  part;  menthol,  0.24  part; 
oil  of  eucalyptus,  0.3  part;  camphor,  0.48  part;  and  28.5  parts  of  a  mix- 
ture of  2.5  parts  of  Peru  balsam  with  100  parts  of  rectified  petroleum. 

Cocain  Tartrate. — A  local  anesthetic,  the  uses  and  dosage  of  which 
are  the  same  as  for  cocain  hydrochlorid.  It  is  a  white,  crystalline  pow- 
der, soluble  in  water  and  alcohol. 

Cocain-Urethane. — By  the  action  of  chlorformic  ester  on  the  amido- 
derivative  of  cocain,  Oocain-Urethane, 


(COOC2H5)NH— CH 


CH.COOCH3 


CH.OCCfiHsCO) 


CH,, 


is  produced.  This  is  said  to  be  a  strong  anesthetic,  acting  on  the  liver 
in  a  characteristic  manner  and  giving  rise  to  toxic  symptoms. 

Cocainol. — A  Berlin  firm  has  placed  various  forms  of  this  external 
remedy  on  the  market;  these  all  contain  anesthesin  (Eitsert's),  but  no 
cocain.  Among  the  forms  are :  Oocainol-menthol  drops,  cocainol  tab- 
lets, and  cocainol  drops.  The  latter  contain  0.2  gm.  of  anesthesin  each. 
Hemostatic  cocainol  bougies  contain  10  per  cent  of  anesthesin  and 
0.0001  gm.  of  suprarenin;  there  are  also  listed  cocainol  bismuth  tablets, 
cocainol  quinin  tablets,  cocainol  condurango  tablets,  and  cocainol  sano- 
form  dusting  powder.     See  Pharm.  Ztg.,  ^7,  916. 

Cocainolbalsam,  Schmerzstillender. — This  salve  contains  vaselin, 
menthol,  methyl  salicylate,  and  anesthesin. 

Cocainol-Creme. — This  contains  anesthesin,  aluminum  beta-naph- 
tholdisulphonate,  zinc  acetate  and  thymol  (Chem.  Centr.,  1909,  ii,  1584). 
According  to  Oelie's  Codex  (Xov.,  1910,  311),  sanovagin  (cocainol- 
creme)  is  "a  combination  product  of  anesthesin  with  B-naphtholsulphon- 


728  ANESTHESIA 

ate  of  aluminum-zinc  acetate,  methyl  cTi-iodosalicylate,  mercury  oxycy- 
anid,  and  thymol.''  It  is  used  in  the  treatment  of  genito-urinary  dis- 
eases, especially  those  of  the  female  organs. 

Cocainol-Lbsungen. — Sterilized  solutions  of  0.7  per  cent  subcutin 
dissolved  in  .water, 

Cocainum  Arabinicum. — Employed  in  lumbar  anesthesia.  See 
GunimitropaJiokain. 

Co-Capsulin. — This  anesthetic  and  hemostatic  contains  alcohol,  2  per 
cent;  cocain,  0.5  per  cent;  and  supracapsulin,  1:2000. 

Codrenin. — Two  forms  of  this  preparation,  which  is  used  as  a  local 
anesthetic  and  hemostatic  in  dentistry,  are  offered,  of  different  strengths, 
in  ounce  bottles,  namely: 

"A" — Each  fluid  ounce  contains: 

Cocain  hydrochlorid  (2  per  cent) 9  1/5    grs. 

Adrenalin  chlorid    (1 :15,000) 1/36  gr. 

Chloretone   2  1/4    grs. 

"B" — Each  fluid  ounce  contains: 

Cocain  hydrochlorid   (1  per  cent) 4  3/5    grs. 

Adrenalin  chlorid  (1 :5,000) 1/12  gr. 

Chloretone   2  1/4    grs. 

The  chloretone  is  said  to  be  added  not  because  of  any  local  anes- 
thetic effect,  but  specifically  to  prevent  the  growth  of  fungus.  Eor  this 
purpose  it  is  said  to  have  been  found  to  be  most  efficient,  more  so,  in 
fact,  than  all  of  the  preservatives  known  in  solutions  of  the  alkaloids 
or  similar  substances  employed  hypodermatically. 

Cold. — On  the  production  of  local  anesthesia  by  means  of  refrigera- 
tion or  cold,  see  the  following  contributions : 

Arnott:  "On  Cold  as  a  Means  of  Producing  Local  Insensibility," 
La7icet,  1848,  3,  98,  287. 

Bailly:  "Kouveau  precede  de  refrigeration  locale  par  le  chlorure  de 
methyle,"  Gaz.  lield.,  1888,  No.  5. 

Baudouin:  "Chlorure  d'ethyle  comme  anesthesique  locale,"  Progres 
mU.,  1892. 

Berger:  "Bromathyl  als  Lokalanastheticum,"  Breslauer  drztl.  Z., 
1883,  No.  8. 

Bernard:  "Anesthesie  locale  par  le  sulfure  de  carbone,"  Gaz.  med., 
1874,  27. 

Bigelow:    Gaz.  liebd.,  1866,  No.  23. 

Bloch.  "Om  Indskrankning  i  Anvendelse  af  Inhalationsanasthesi," 
NordisU  med.  Arhiv,  1899,  No.  33 ;  BiUiotheh  for  Laeger,  1898. 

Boeri  and  Silvestro:  "Sur  la  mode  de  se  comporter  des  differentes 
sensibilites  sous  faction  des  divers  agents,"  Archiv.  Ital.  d.  Biol,  31,  460. 


A   LIST    OF    ANESTHETICS  729 

Braatz:    "Zur  Lokalanastliesie/'  Zeniralbl.  f.   Chir.,,   1895,  No.  2G. 

Bumm:   "tJber  lokale  Anasthesierung,"  Wiener  Klinilc,  1886. 

Cardenal:     "Une  decouverte  de  Dr.  Letaraendi  sur  I'anesthesie  lo- 
cale/' Archiv.  d.  physiol.  norm,  et  pathoL,  1875,  S,  769. 

Debove:    "Traitement  de  la  sciatique  par  la  congelation/'  iSociete 
med.  des  hop.,  Aug.,  1884. 

Delcominete :    Gaz.  des  hop.,  1866,  No.  45. 

Ehrmann:    "Athylchlorid   als  Lokalanastheticum  in   der   Dermato- 
therapie/'  Wiener  med.  Woch.,  1893,  No.  26. 

Feiber:    "Chlormethyl  als  lokales  Anastheticmn/'  Berl.  Iclin.  Woch., 
1889,  No.  5. 

Fratscher:    "^Kontinuierliche  und  langsame  Nervenreizung,"  Jena. 
Z.  f.  Naturkunde,  11,  481. 

Galeezowski :    "De   I'anesthesie  locale   dans   la   chirurgie   oculaire," 
Eec.  d'ophthal.,  1876,  93. 

Ganz :   "tJber  Athychlorid,"  Therap.  Monatsh.,  1893,  113. 

Gendre:    Einfluss  der  Temperatur  auf  einige  tierisch-elektr.     Er- 
scheinungen,"  Pfliigers  Archiv,  3J/.,  423. 

Giraldes :     "Anesthesie  chirurgicale,"  in  "Nouveau  dictionnaire  de 
medecine  et  de  chirurgie,"  Paris,  1865. 

Girard:    "Zur    Erleichterung    der    Lokalanasthesie,"    Zentralbl.    /. 
Chir.,  1874,  No.  3. 

Griitzner:    "tJber  verschiedene  Arten   der  Nervenerregung/'   Pflii- 
gers Archiv,  17,  315. 

Guerard:    Gaz.  des  hop.,  1854,  88. 

von  Hacker:    "Zur  lokalen  Anasthesie,"  Wiener  hlin.  Woch.,  1893. 

Hattyasi:    "Yersuche  mit  Athylchlorid/'  Pester  med.  Chir.  Presse, 
1893,  No.  33. 

Heinzmann:    "tJber   die   Wirkung  allmahlicher   Anderungen   ther- 
mischer  Beize,"  Pfliigers  Archiv,  6,  333. 

Herzog:    N eue  Zeitung  filr  Mediziii,  1S50. 

Husemann:     Virchow-Hirsch  Jahre.,  1866,  1,  344;  1867,  1,  501. 

Illich :    Med.  Ztg.  Russlands,  1853,  No.  55,  and  1853,  No.  15. 

Kiimmell:    "Uber  Narkose  und  lokale  Anasthesie,"  Festschr.  z.  SO 
jdhr.  Stiftung.  des  drztl  Vereins,  Hamburg,  Leipzig,  1896. 

Lauenstein:     "Die   lokale   Anasthesie  durch   Ather,"   Zentralbl.   f. 
Chir.,  1880,  497. 

von   Lesser:     "Demonstration   zur   lokalen   Anasthesierung/'    Deut. 
Chir.,  1881. 

Letamendi:    "Un  pas  vers  la  resolution  du  probleme  de  I'anesthesie. 
locale,"  Barcelona,  1895. 

Letang:    "Note  sur  un  nouveau  procede  d'anesthesie  locale,"  These, 
Paris,  1894. 

^xxm.:    Lancet,  Aug.,  1850. 


730  ANESTHESIA 

Eedard:  "Chlorathyl  als  Lokalanastheticum/'  La  sem.  med.,  1891, 
133. 

Eichardson:  Med.  Times,  1866. 

Eichardson  and   Greenhalgh:    Med.    Times,  1866. 

Eichet:  "Anesthesie  localisee/'  Gaz.  des  Hop.,  1854,  251,  263,  267; 
Bull,  de  la  Soc.  de  Chir.,  J/.,  519. 

Eosenthal:  "Experimentelle  und  praktische  Beitrage  zur  Einwirk- 
ung  der  Lokalanasthesie  auf  das  Nervensystem,"  Osterr.  Z.  f.  Heil- 
hunde,  1867,  373. 

Eossbach:  "Eine  neue  Anasthesierungsmethode  des  Kehlkopfs,^' 
Wiener  med.  Presse,  1880,  No.  40. 

Eottenstein :  Tagehlatt  d.  Versammlung  deut.  Natur.  u.  Arzte  in 
Frankfurt  a.  M.,  1867,  43. 

Scheller:  "Eeines  Athylchlorid  als  ortliches  Anastheticum  und  An- 
tineuralgicum,"  Deut.  Monats.  f.  Zahnheil.,  1891,  No.  5. 

Simonin:     Gaz.  Med.  de  Paris,  1866,  jSTo.  11. 

Terillon:  "Anesthesie  locale  et  generale  produite  par  le  bromure 
d'ethyle,"'  Gaz.  Med.  de  Paris,  1880,  No.  22. 

Velpeau :    Bull,  de  V Academie  de  Med.,  15,  85. 

Warren:    "Surgical  Observations,"  Boston,  1867. 

Wells,  Spencer:    Med.  Times,  1866. 

Wiesendenger :  "Fliissige  Kohlensaure  als  Lokalanastheticum,"  J.  f. 
Zahnheilk.,  1891,  No.  21. 

Wittmeyer :   "tJber  Anasthesie,"  Deut.  Klinik,  1852,  No.  19. 

Compound  Anesthetic  Ether. — A  mixture  of  equal  parts  of  absolute 
ether  and  amyl  hydrid   (rhigolene)    (Eichardson,  1868). 

Eichardson  (Sci.  Am.  Suppl.,  No.  516,  8240)  states  that  this  mix- 
ture possesses  a  density  of  0.672  and  boils  at  -[-90°  F.  He  found  that 
it  is  pleasant  to  breathe  and  that  it  is  a  rapidly  acting  anesthetic,  but 
that  it  is  dangerous,  causing  death  in  the  lower  animals,  suddenly,  from 
cardiac  paralysis.  "It  is  not  recommendable  as  a  general  anesthetic, 
and  has  once  been  a  cause  of  death  in  man.  For  producing  local  an- 
esthesia from  cold  in  the  form  of  a  spray  it  is  good  and  is  generally  em- 
ployed"  (1885). 

Compressed  Lozenges  Orthoform,  1  g^^ain. — Each  lozenge  contains 
orthoform  (q.  v.),  0.065  gm.  (1  grain). 

Compressed  Tablets  Anesthesin,  2y2  grains. — Each  tablet  contains 
anesthesin  (q.  v.),  0.162  gm.  (21^  grains). 

Conephrin. — A  solution  containing  cocain  and  paranephrin,  used 
as  a  local  anesthetic. 

Corona. — This  is  a  local  anesthetic,  put  on  the  market  by  a  Leipzig 
firm,  claimed  to  consist  of  a  solution  of  less  than  1  per  cent  of  cocain 
in  distilled  water,  with  the  addition  of  picric  acid,  nitric  acid,  oils  of 
wintergreen,  thyme,  mentha  arvensis,  and  eucalyptus,  and  benzoic  and 


A   LIST    OF    ANESTHETICS  731 

boric  acids.  It  is  employed  in  painless  dentistry.  It  is  stated  in  Gelie's 
Codex  (Nov.,  1910,  88)  that  "corona"  contains,  besides  coeain,  nitric 
acid,  picric  acid,  potassium  hydroxid,  oils  of  gaultheria,  baptisia,  thyme, 
mentha  arvensis  and  eucalyptus,  benzoic  acid  and  boric  acid,  in  water 
solution. 

Coryl. — See  Chloryl. 

Coryloform. — An  anesthetic  mixture  containing  ethyl  chlorid,  methyl 
chlorid,  and  ethyl  bromid.     See  Pharm.  Ztg.,  53,  817. 

Coumarin. — Ellinger  (Archiv  exper.  Pathol.  Pharmakol.,  1908, 
Suppl.)  found  that  in  frogs  injections  of  0.03  to  0.05  gm.  of  coumarin, 
the  anhydrid  of  coumaric  acid-,  caused  deep  anesthesia  of  the  nervous 
centers  in  the  brain  and  spinal  cord,  extending  to  the  vagus  and  the 
respiratory  center,  while  the  vasomotor  center  was  not  paralyzed  and  the 
functions  were  not  demonstrably  altered.  In  rabbits  injections  of  0.15 
to  0.2  gm.  per  kg,  body  weight  produced  deep  anesthesia  lasting  about 
10  minutes.  He  concluded  that  coumarin  was  a  harmless  anesthetic 
when  properly  administered,  and  that  it  was  not  a  dangerous  cardiac 
poison  as  claimed  by  Kohler  (Zentr.  f.  d.  med.  Wissenschaft.,  1875,  867 
and  881).  Cianci  (Giornale  Internaz.  delle  Sci.  med.,  1908,  Nov.) 
ascribed  to  coumarin  an  action  resembling  that  of  camphor. 

Creme  Dehne. — A  salve  of  the  following  formula : 


Extr.  Hamamel.  destill 30.0 

aa 5.0 


Acidi  borici ) 


Anesthesin 

Ad.  Lanae  c.  aqua 55.0 

Camphor. 

Essent.  Heliotrop.    -  aa    1.0 

Essent.  Eosemar. 

Creosote. — Used  in  dentistry,  as  a  local  anesthetic.  See  Carholic 
Acid. 

Cycloform. — This  compound  is  the  isobutyl  ester  of  para-amido- 
benzoic  acid;  it  is  a  white  crystalline  powder,  melting  at  -f-  65°  C, 
sparingly  soluble  in  water,  but  readily  soluble  in  alcohol  and  ether. 

Impens  (Therap.  d.  Gegenwart,  1910,  No.  8)  showed  that  cycloform 
has  the  advantage  that  it  dissolves  in  water  only  to  the  amount  of  0.023 
per  cent;  this  sparing  solubility  leads  to  an  entirely  local  action  and 
prevents  symptoms  due  to  absorption.  Impens  found  the  anesthetic 
action  of  cycloform  to  be  very  great. 

On  cycloform,  see  also: 

Krecke :    Milnch.  med.  Woch.,  1910,  2447. 

Most:   Heilkunde,  1910. 

Strauss :   Milnch.  med.  Woch.,  1910,  No.  50,  2643. 

Wyss:    Archiv  f.  Verdauungs-Krankheiten,  16,  No.  4. 


732  ANESTHESIA 

Werner :   Milnch.  med.  Wocli.,  1910,  No.  38,  2004. 

Zeller:   Med.  Klinilc,  1910,  No.  45,  1748. 

Bircher:    Idem,  1911,  No.  6,  223. 

Rosenberg:   Deut.  med.  Woch.,  1911,  No.  9,  409. 

Cycloform  appears  from  these  reports  to  be  non-irritant,  prompt  and 
intense  in  anesthetic  action. 

Cyclorenal. — A  combination  of  cycloform,  adrenalin,  balsam  Peru, 
and  coryfin,  made  in  Berlin,  in  the  form  of  salves  and  suppositories  for 
the  treatment  of  rectal  diseases.  See  Kretschmer :  Berl.  Min.  Woch., 
1911,  J^8,  2168.  Rabow  (Chem.  Ztg.,  1912,  No.  21,  190)  states  that 
cyclorenal  is  a  local  anesthetic. 

Bentesthin. — A  dental  local  anesthetic  containing  in  1  c.  c.  of  a 
physiological  salt  solution  0.005  gm.  cocain  hydrochlorid,  0.015  gm.  novo- 
cain, and  0.05  gm.  of  synthetic  suprarenin.  See  Pharm.  Zentralh.,  51, 
1126. 

Dentalon  or  Dentalone. — This  dental  local  anesthetic  is  a  combina- 
tion of  chloretone  {q.  v.)  and  several  essential  oils,  and  is  used  spe- 
cifically in  the  treatment  of  exposed  nerves  and  decaying  teeth.  It  has 
been  found  to  be  a  very  practical  and  satisfactory  obtundent.   ■ 

Each  fluid  ounce  of  dentalone  contains  approximately: 

Oil  Cloves    300  min. 

Oil  Birch    12  min. 

Oil  Cinnamon 50  min. 

Chloretone    175  min. 

The  label  bears  the  information  that  dentalone  is  an  admixture  of 
the  oils  of  cloves,  cassia,  and  gaultheria,  containing  in  solution  30  per 
cent  of  their  weight  of  chloretone;  that  is  175  gr.  of  chloretone,  and 
Oils  of  Cloves,  Gaultheria,  and  Cassia  {q.  v.),  to  each  fluid  ounce. 

Dentola. — This  contains  cocain,  1 ;  potassium  bromid,  10 ;  glycerin, 
200;  and  water,  200.     It  is  used  in  dentistry. 

Dentorol. — "Eugenol-para-chloro-chlorphenol-Menthol.''  It  is  used 
in  dentistry.  '    '■' 

Desalgin. — Schleich  {TJierap.  d.  Gegenwart,  1909,  1,  138)  succeeded 
in  combining  chloroform  with  an  albumin  and  in  procuring  a  definite 
compound  with  a  fairly  constant  percentage  of  about  25  per  cent  of 
chloroform  in  the  dry  state.  This  preparation  is  a  gray,  amorphous, 
fine  powder;  it  represents  "colloidal  chloroform''  in  a  solid  state,  and 
may  find  application  in  anesthesia.  >  '■' 

Dialkylaminoalkyl  3 :  4-Diaminobenzoates. — According  to  Einhom 
(German  Patent  194,365),  these  compounds  have  considerable  local  an- 
esthetic properties.  ■    ■      .  -  ;    ; 

Dibromethane.^See  Ethylene  Bromid. 


A    LIST    OF    ANESTHETICS  733 

Dichlor ethane. — This  ester,  CIIg.CHCL,  is  said  to  have  a  similar 
action  to  chloroform. 

Dichlormethane. — See  Methylene  Chlorid. 

Dichlorpropane. — According  to  Brissemoret  and  Chevalier  (Compt. 
rend.,  IJfS,  731),  2,  2— Dichlorpropane,  CH3C(Cl2).CH3,  is  a  fugitive 
anesthetic  not  to  be  considered  the  superior  of  ethyl  chlorid. 

Diethylaminoethyl  Benzoate. — This  dialkylaminoethyl  benzoate,  de- 
scribed by  Schering  (German  Patent  175,080),  has  been  stated  to  have 
local  anesthetic  properties. 

Dimethylacetal  (Ethylidene  dimethyl  ether),  CH3CH(0CH3)2.— An 
anesthetic  used  in  the  place  of,  or  with,  chloroform.  It  is  prepared 
from  aldehyd,  methyl  alcohol,  and  glacial  acetic  acid  by  the  action  of 
heat.  It  forms  a  colorless  liquid,  soluble  in  water,  alcohol,  ether,  and 
chloroform;  the  specific  gravity  is  0.879  at  0°  C.  and  the  boiling  point 
-f-  62°  to  63°   C.     See  von  Mering's  Mixture. 

Dioform. — Dioform,  or  acetylene  dichlorid,  is  a  colorless  fluid  with 
an  odor  resembling  that  of  ethyl  chlorid  and  chloroform.     Its  graphic 

CH  CI 
formula  is  (symmetrical  1.2-dichlorethylene).     Its  specific  grav- 

CH  CI 
ity  is  1.29  and  it  boils  at  about  -|-  55°  C. 

Villinger  {Archiv  f.  hlin.  Cliir.,  1907,  No.  3 ;  Zentr.  f.  Chir.,  1907, 
No.  44,  1282;  Odontol.  Blatter,  1907,  No.  17,  327)  conducted  some 
experiments  with  dioform  on  dogs  with  the  view  of  ascertaining  whether 
the  narcotic  action  resembled  that  of  chloroform.  He  produced  nar- 
cosis lasting  10  minutes  to  2  hours,  and  gave  doses  up  to  125  gm.  with- 
out observing  any  threatening  symptoms.  Sleep  set  in  within  6  to  10 
minutes,  and  was  preceded  by  only  a  short  stage  of  excitation.  The  re- 
flexes were  completely  abolished  during  sleep,  while  the  strength  and 
frequency  of  the  pulse  remained  constant.  The  urine  remained  almost 
normal,  so  that  there  was  no  reason  to  suspect  inflammation  of  the 
kidneys.  The  trials  made  by  Villinger  on  human  subjects  also  gave  sat- 
isfactory results.  15  to  25  gm.  of  dioform  were  used;  after  about  a 
minute,  slight  excitation  was  observed;  after  3  minutes  more,  sleep 
ensued,  to  become  deep  sleep  5  minutes  after  the  beginning  of  the  an- 
esthesia. Pulse  and  respiration  remained  good,  the  patients  awakened 
quickly,  there  was  but  slight  tendency  to  vomit,  and  no  albumin  was 
found  in  the  urine.  However,  systematic  clinical  study  is  required  be- 
fore acetylene  dichlorid  should  be  used  as  a  substitute  for  chloroform. 

Dionin.- — Dionin  (ethyl-morphin  hydrochlorid)  is  a  white,  some- 
what bitter  powder  fusing  at  -j-  123°-125°  C;  it  is  soluble  in  seven 
parts  of  water,  one  and  one-half  parts  of  alcohol,  and  twenty  parts  of 
syrup;  it  is  insoluble  in  chloroform  and  ethyl  ether.  Dionin  is  pre- 
cipitated from  its  solutions  by  most  of  the  alkaloidal  reagents. 


734  ANESTHESIA 

Dionin  has  been  reported  upon  by  a  number  of  observers;  it  would 
seem  that  it  shares  the  analgesic  and  hypnotic  properties  of  morphin 
without  producing  the  nausea,  constipation,  and  other  disagreeable 
after-effects  of  that  alkaloid.  However,  it  acts  even  more  powerfully 
upon  the  respiratory  centers  than  does  morphin.  According  to  The 
Dispensatory  of  the  United  States  of  America,  19th  ed.,  1473,  it  is, 
nevertheless,  less  decisive  in  its  action  than  is  morphin,  so  that  in  cases 
of  severe  pain  morphin  will  bring  relief  after  the  failure  of   dionin. 

A  5  per  cent  solution  of  dionin  has  been  used  by  ophthalmologists; 
it  occasions  immediate  irritation  and  swelling  of  the  conjunctiva,  fol- 
lowed, in  a  short  time,  by  a  rapid  subsidence  of  the  swelling  and  a  con- 
dition of  analgesia  and  anesthesia. 

The  employment  of  dionin  in  local  anesthesia  has  been  discussed 
by  the  following  authors: 

Graefe:  "Das  Dionin  in  der  Augenheilkunde,"  Deut.  med.  Woch., 
1900,  Therap.  Beil.,  No.  2. 

Wolffberg:  "Die  Dioninophthalmie  und  ihre  Bedeutung,"  Therap. 
Monatsh.,  May,  1900. 

Di-para-anisyl-monophenetyl-g^anidin  hydrochlorid. — See  Acoin. 

Dipropesin. — This  seems  {Apoth.-Ztg.,  1908,  786;  Yierteljahr.  f. 
prak.  Pharm.,  1908,  305;  Pharm.  Ztg.,  63,  817)  to  be  a  derivative  of 
urea,  containing  two  molecules  of  propesin  {q.  v.)  bound  together  by 
a  CO  group: 

.NH CeHi COOCjHt 

/ 

CO 

\ 

^NH CsH* COOC3H7 

Dipropesin  is  described  as  a  white  crystalline  powder  melting  at 
-\-  171-172°  C,  tasteless  and  soluble  in  alcohol,  but  insoluble  in  water. 
It  is  said  to  develop  its  anesthetic  action  only  in  alkaline  media,  and  to 
be  therefore  of  use  as  an  internal  sedative  in  intestinal  affections. 

Kluger  {Therap.  Monats.,  1909,  76)  published  clinical  reports  on 
the  use  of  dipropesin.  He  stated  that  dipropesin  has  no  anesthetic 
effect  until  propesin  {q.  v.)  is  liberated  in  the  alkaline  body  fluids. 

Dolonephran. — An  anesthetic  of  German  manufacture,  said  to  con- 
tain alypin  {q.  v.),  suprarenin,  and  sodium  chlorid. 

Dolorant  Tablets. — Each  of  these  tablets  of  Swiss  preparation  is 
said  to  contain  0.0001  gm.  of  adrenalin,  0.01  gm.  of  cocain,  0.002  gm.  of 
sodium  chlorid.  When  dissolved  in  water,  the  solution  is  used  in  the 
painless  extraction  of  teeth. 

Dolorant  Tabletten.^ — Each  tablet  contains  0.00001  gm.  adrenalin, 
0.01  gni.  cocain,  and  0.00499  gm.  sodium  chlorid.    One  to  four  tablets  are 


A   LIST    OF    ANESTHETICS  735 

dissolved  in  1-4  c.  c.  of  water  for  use  in  the  production  of  loeal  anesthesia 
in  dentistry  (Gehe's  Codex,  Nov.,  1910,  100). 

Dolorifuge. — A  mixture  of  creosote,  1 ;  chloroform,  1 ;  and  ethyl 
acetate,  2.     It  is  used  in  dentistry. 

Dontocerat. — See  Ceratum  Odonialgicum. 

Dutch  Liquid;  Elayl  Chlorid. — See  Ethylene  Chlorid. 

Dysphagin. — No  I.  Tablets  containing  cocain,  menthol,  anesthesin, 
sodium  biborate,  and  aromatics;  No.  II.  The  same,  but  without  cocain; 
No.  III.   Anesthesin,  citric  acid,  tannin,  and  aluminum  acetate. 

Dysphagin  is  used  in  the  treatment  of  angina  and  throat  affections. 

Elayl  Chlorid. — See  Ethylene  Chlorid. 

Electric  Analgesia. — On  Electric  Analgesia  and  Sleep,  see  Chapter 
XVI. 

Enophthalmin. — The  hydroehlorid  of  oxytouyl-methyl-vinyl-di-ace- 
tonalkamin,  slightly  soluble  in  water.  Used,  in  2  per  cent  solution,  as  an 
anesthetic  in  ophthalmology. 

Ensemin. — A  solution  of  about  1  per  cent  cocain,  containing,  in  addi- 
tion, adrenalin  anfl  chloretone.    Used  as  a  dental  anesthetic. 

Epicain. — A  solution  containing  cocain  hydroehlorid  and  epinin 
(dihydroxyphenylethylmethylamin),  marketed  also  as  tabloid  ophthal- 
mic epicain. 

Erhardt's  Solutions. — These  are  solutions  for  lumbar  anesthesia,  con- 
sisting of  salts  of  arabic  acid  with  certain  anesthetic  bases,  as  cocain, 
tropacocain,  stovain,  novocain,  etc.  See  German  Patent  211,800  of 
1908;  and  also  Erhardt:  Woch.  f.  Tierheilkunde,  1908,  Nos.  27  and  28; 
Mimch.  med.  Woch.,  1908,  Nos.  19  and  26. 

Epsom  Salts. — A  saturated  solution  of  magnesium  sulphate  has  been 
employed  as  a  dental  local  anesthetic;  it  is  said  to  be  very  satisfactory. 
See  Magnesium  Salts. 

Erythrophlein  Hydroehlorid,  ErythrophlcEinum  Hydrochloricum 
(Erythrophleinae  Hydrochloras). — This  salt  of  an  alkaloid  from  the 
bark  of  Erythrophloeum  guinense,  Don.  (sassy  bark),  is  used  as  a  local 
anesthetic  in  eye  practice  in  0.05  to  0.25  per  cent  solutions.  It  forms 
a  yellowish-white  amorphous  powder,  soluble  in  water  and  alcohol.  Its 
solutions  are  not  stable.  On  the  physiological  action  of  Erythrophlein 
Hydroehlorid,  see  Harnack:  Berl.  hlin.  Woch.,  1895,  759,  On  its  em- 
ployment as  a  local  anesthetic,  see  the  following  papers : 

Brandt:  "Versuche  mit  Erythrophlaein  bei  Odontalgic/^.  Therap. 
Monatsh.,  June,  1888. 

Guttmann :  "Versuche  mit  Erythrophlaein,"  Berl.  Tclin.  Woch.,  1888, 
No.  13. 

Hirschf eld :    "Ueber  Erythrophlaein,"  iUd.,  1888,  No.  11. 

Karewski :  "Ueber  die  praktische  Verwendbarkeit  der  Erythro- 
phlaein-anasthesie,"  ihid.,  1888,  No.  11. 


736  ANESTHESIA 

Koller:   "Erythrophlaein,"  Wiener  klin.  Woch.,  1888,  No.  6. 

Lewin:  "Ueber  das  Hayagift  iind  das  Erythrophlaein,"  \R<?H.  kUn. 
Wocli.,  1888,  No.  9;  Virchows  Archiv,  111,  575;  "Bemerkungen  zu 
Liebreichs  Arbeit  iiber  Erythrophlaein,"  Berl.  klin.  Woch.,  1888,  No.  9. 

Liebreich:  "Erythrophlaein,"  Tlierap.  Monatsh.,  March,  1888; 
"Ueber  die  Wirkung  der  N-Cassa  Einde  und  des  Erythrophlaein,"  BerJ. 
klin.  Woch.,  1888,  No.  9 ;  "Haya  und  Erythrophlaein,"  ibid.,  1888,  No. 
16. 

Lipp :  "Wirkungen  des  Erythrophlaein,"  Wiener  klin.  Woch.,  1888, 
No.  11,  12. 

Loewenhardt:  "Zur  praktischen  Verwertung  des  Erythrophlaein," 
Berl.  klin.  Woch.,  1888,  No.  10. 

Onodi:    "Versuche  mit  Erythrophlaein,"  Med.  Zentr.,  1888,  No.  12. 

von  Eeuss:  "Ueber  Erythrophlaein,"  Internat.  klin.  Rundschau, 
1888,  No.  9. 

Scholer:  "Bemerkungen  liber  Erythrophlaein,"  Berl.  klin.  Woch.^ 
1888,  No.  10. 

Tweedy:    "Erythrophlaeine,"  iancef,  1888,  249. 

Ethene. — Olefiant  Gas  was  proposed  as  an  anesthetic  by  Nunneley 
in  1849.  B.  W.  Eichardson  investigated  it  in  1865;  he  reported  later 
(Sci.  Am.  Suppl,  No.  515,  Nov.  14,  1885,  8228)  that  it  was  a  good 
anesthetic,  but  inconvenient  at  that  time  on  account  of  its  being  a  gas. 
He  found  that  the  respiration  ceased  before  the  circulation.  Anesthesia 
was  found  to  be  rapidly  produced  with  a  10  to  15  per  cent  charge  of 
air  by  gas,  with  a  short  spasmodic  stage;  recovery  was  rapid,  without 
bad  effects. 

Ether.— See  Ethyl  Ether,  Chapter  V.  ■ 

Ether-Menthol-Chloroform. — This   anesthetic  spray  is  composed  of 
ether,  15  parts;  chloroform,  10  parts;  and  menthol,  1  part. 
Ethidene  Dichlorid. — See  Ethylidene  Chlorid. 

Ethyl  Acetate  (Acetic  Ether;  "Vinegar  Naphtha"). — This  com- 
pound has  been  used  as  an  external  anesthetic. 

Acetic  Ether  TJ.  S.  P.  consists  of  about  90  per  cent  by  weight  of 
CH3CO.OC2H5  and  about  10  per  cent  of  ethyl  alcohol  containing  a 
little  water.  It  is  soluble  in  about  9  parts  of  water  at  +  25°  C,  but  is 
miscible  in  all  proportions  with  alcohol  and  ether. 

H.  C.  Wood  found  ethyl  acetate  to  be  capable  of  being  used  as  an 
anesthetic,  but  to  be  too  slow  in  its  action  for  practical  purposes.  Its 
action  on  the  system  is  probably  very  similar  to  that  of  ethyl  -ether ; 
but,  since  it  is  less  volatile,  it  is  less  rapidly  absorbed  and  eliminated, 
and  therefore  is  much  less  prompt  and  is  fugacious.  Kappeler  recorded 
eases  in  which  ethyl  acetate  was  administered  to  man.  Tracy  was  op- 
posed to  its  use,  and  Sigmund  and  Bouisson  found  it  less  agreeable  and 
efficient  than  ether. 


A   LIST    OF    ANESTHETICS  737 

Ethyl  Alcohol. — Alcohol  was  used  by  Horvath  {Gaz.  des  Hopitaux, 
Sept.  10,  1878)  for  the  production  of  local  anesthesia.  It  had  been 
used  previously  by  surgeons  to  produce  immunity  from  pain  in  opera- 
tion, and  Lynk  ((7m.  Lancet  and  Observer,  May,  1876)  stated  that 
he  had  long  employed  it  as  an  anesthetic.  Turnbull  (1879)  recom- 
mended inhalation  of  dilute  alcohol. 

Ethyl  Aminobenzoate  (.ffithylis  Amino-Benzoas ;  Paramidobenzoic 
Acid  Ethyl  Ester) .—Ethyl  aminobenzoate,  C^ll^.^iL..COO{C^llrJ  1:4, 
is  the  ethyl  ester  of  paraminobenzoic  acid,  CgH^.NHo.COOH,  1 :  4. 

Paranitrobenzoic  acid  is  obtained  by  the  oxidation  of  paranitrotol- 
uene,  and  this  may  be  ethylized  by  the  action  of  sulphuric  acid  and  al- 
cohol, and  the  ester  so  obtained  reduced  to  paramidobenzoic  acid  ethyl 
ester  by  the  action  of  nascent  hydrogen,  or  the  acid  may  first  be  reduced 
and  subsequently  converted  into  the  ethyl  ester.  It  is  a  white,  crystal- 
line powder,  easily  reduced  to  impalpability,  melting  at-|-90°to-}-91° 
C.  (194°  to  195.8°  F.)  ;  odorless  and  tasteless,  but  producing  a  sensa- 
tion of  numbness  when  placed  on  the  tongue;  almost  insoluble  in  cold 
and  difficultly  soluble  in  hot  water;  soluble  in  six  parts  of  alcohol,  in 
ether,  benzene,  and  to  the  amount  of  2  to  3  per  cent  in  fatty  oils.  In 
oil  solutions  it  may  be  sterilized  without  decomposition,  but  by  pro- 
longed boiling  or  by  warming  with  dilute  alkalies  it  is  split  up  into 
alcohol  and  paramidobenzoic  acid. 

It  should  form  clear,  colorless,  and  neutral  solutions  in  alcohol  or 
ether;  after  acidification  with  nitric  acid,  it  should  not  give  a  precipi- 
tate with  silver  nitrate.  Its  solution  in  dilute  hydrochloric  acid  (1  to 
10)  is  not  affected  by  hydrogen  sulphid.  If  a  few  drops  of  sodium 
nitrate  solution  are  added  to  the  slightly  acidulated  water  solution  fol- 
lowed by  some  alkaline  beta-naphthol  solution,  a  cherry  red  coloration  of 
bluish  shade  is  produced,  which  changes  to  orange  on  further  addition 
of  hydrochloric  acid.  It  is  decomposed  by  prolonged  heating  with  water, 
and  is  incompatible  with  alkalies  and  their  carbonates. 

Ethyl  aminobenzoate  was  introduced  as  a  substitute  for  cocain  and 
is  a  local  anesthetic,  similar  in  its  action  to  orthoform  and  said  to  be 
equally  effective,  but  free  from  irritant  action  and  toxicity.  The  anes- 
thetic action,  like  that  of  the  related  compound  orthoform  (g.  v.),  re- 
sembles that  of  cocain,  but  is  purely  local,  does  not  penetrate  the  mu- 
cous membranes,  and,  in  consequence  of  its  insolubility,  the  compound 
cannot  be  used  by  hypodermic  injection.  In  consequence  of  its  in- 
solubility, also,  the  anesthetic  effect  is  more  prolonged  than  that  of 
cocain. 

It  is  said  to  be  useful  for  the  relief  of  pain  in  various  forms  of  gas- 
tralgia,  in  ulcer  and  cancer  of  the  stomach,  and  is  applied  locally  in 
rhinologic  and  laryngeal  affections,  urethritis,  etc.;  it  is  also  employed 
for  anesthetizing  wounded  surfaces,  burns,  ulcerations,  and  painful  af- 


738  ANESTHESIA 

fections  of  the  skin.     It  is  more  effective  in  cases  where  the  skin  is 
broken. 

Dosage. — Internally,  0.3  to  0.5  gm.  (5  to  8  grains),  in  pastilles.  Ex- 
ternally it  is  applied  as  a  dusting  powder,  either  pure  or  diluted.  It 
may  be  applied  in  ointment  or  in  the  form  of  suppositories.  See  Anes- 
tli  esin. 

Ethylbenzoylecgonin. — A  local  anesthetic. 

Ethyl  Bromid  (Monobromethane;  Hydrobromic  or  Bromic  Ether). — 
By  many,  ethyl  bromid  is  considered  to  be  an  efficient  and  safe  inhala- 
tion and  local  anesthetic.  T.  Nunneley,  who  introduced  ethyl  bromid 
as  an  anesthetic  in  1849,  considered  it  to  be  one  of  the  best  of  anes- 
thetics, in  which  view  Eichardson  (Sci.  Am.  Suppl.,  No.  515,  8328) 
concurred.  The  latter  pointed  out,  in  1885,  that  the  objections  to  its 
use  were  its  cost  and  instability;  that  no  deaths  from  it  had  occurred 
in  the  human  subject,  and  that  in  death  induced  by  it  in  the  lower  ani- 
mals the  respiration  and  circulation  failed  together.  He  stated  that 
the  quantity  required  for  complete  anesthesia  was  1  to  6  fluid  drachms, 
and  that  the  required  charge  of  air  by  vapor  was  5  to  10  per  cent.  Its 
action  was  found  to  be  rapid  and  effective,  with  scarcely  any  second  or 
spasmodic  stage;  recovery  from  deep  narcotism  was  obtained  in  four 
to  five  minutes,  without  bad  effects;  and  during  full  anesthesia  the 
animal  temperature  was  reduced  2°  F.  M.  Eobin  studied  the  use  of 
ethyl  bromid  in  1850,  and  Eichardson  in  1870. 

On  the  physiological  action  of  ethyl  bromid,  see  Cole:  Brit.  Med.  J., 
June  20,  1903,  1421 ;  and  Webster :  Bio-Chemical  J.,  1906,  1,  328. 

Ethyl  bromid  is  only  slightly  toxic,  but  causes  more  irritation  of  the 
respiratory  passages  than  ethyl  chlorid.  The  narcosis  produced  by 
means  of  it  is  said  to  differ  from  that  of  choloroform  in  that  it  sets  in 
more  rapidly  and  ceases  more  quickly.  Subsequently  the  patient  may 
have  general  mild  depression.  Pain  is  abolished  before  consciousness. 
The  respiration  is  paralyzed  at  about  the  same  time  as  the  reflexes,  so 
that  the  zone  of  safety  is  very  narrow. 

From  the  third  statistical  record  compiled  by  the  Central  Society  of 
German  Dentists  (see  Lipschitz:  Deut.  Monats.  f.  Zahnheilk.,  1905,  No. 
11,  683),  it  is  seen  that  5,973  administrations  of  chloroform,  14,921  of 
ethyl  hromid,  and  1,509  of  ethyl  chlorid  involved  no  fatal  case.  The  mor- 
tality due  to  the  administration  of  these  three  narcotics  was  expressed  as 
follows : 

Ethyl  Bromid 1  :  112,001 

Ethyl  Chlorid 0  :      2,583 

Chloroform 1  :    35,342 

It  is  undoubtedly  true  that  some  of  the  evil  effects  formerly  ob- 
served with  ethyl  bromid  anesthesia  are  attributable  to  unreliable  com- 


A   LIST    OF    ANESTHETICS  739 

mercial  preparations,  but  several  deaths  have  occurred  when  a  pure 
article  was  given.  For  prolonged  anesthesia  ethyl  broraid  is  not  suit- 
able, owing  to  the  fact  that,  after  long-continued  inhalation,  unpleasant 
effects  may  result,  and  in  addition  the  preparation  loses  its  power  if 
administered  for  a  long  time.  It  has  been  found  to  answer  satisfactorily 
in  short  operations,  as  in  dental  surgery  (Eoth:  Prager  med.  Woch., 
1906,  No.  21) ;  and,  as  indicated  by  Merck  {Ann.  Rep.,  20,  22),  its  use 
may  be  recommended  in  cases  where  there  is  a  desire  to  avoid  the  use 
of  cocain  and  adrenalin.  Eoth  concluded  that  ethyl  bromid  is  an  anes- 
thetic which  brings  about  unconsciousness  and  complete  anesthesia  in 
a  very  short  time,  enabling  a  brief  surgical  operation  to  be  completed 
without  hurry,  and  without  fear  of  ill  effects  either  accompanying  or  fol- 
lowing the  anesthesia.  He  considered  that  it  is  very  easy  of  applica- 
tion, in  any  place,  and  without  the  necessity  for  complicated  apparatus. 

Chloroform  anesthesia  is  said  to  be  advantageously  commenced  by 
giving  ethyl  bromid,  since  the  latter  effects  a  more  rapid  abolition  of 
consciousness. 

Breitbach  (Deut.  med.  Woch.,  1911,  374)  stated  that  ethyl  bromid 
is  free  from  danger  when  carefully  used,  and  declares  that  it  is  effective 
for  all  dental  operations. 

On  the  avoidance  of  the  possibility  of  delayed  intoxication  after 
ethyl  bromid  anesthesia,  see  Mounier:  Munch,  med.  Woch.,  1911,  1150; 
he  states  that  the  age  of  the  patient  and  the  presence  of  digestive  dis- 
turbances should  be  especially  considered. 

Ethyl  bromid  must,  however,  be  looked  upon  as  a  dangerous  agent  in 
inexperienced  hands. 

Dosage:  3  c.  c.  to  12  c.  c.  (45  minims  to  3  fluid  drams)  are  suffi- 
cient to  induce  anesthesia.  It  should  be  administered  rapidly,  with 
little  or  no  air.  The  administration  requires  from  20  to  40  seconds; 
the  anesthesia  lasts  about  two  minutes.  The  dose  for  children  should 
not  exceed  1  c.  c.  per  year  of  age. 

It  should  be  protected  from  the  light,  and  a  bottle  or  tube  once 
opened  should  be  used  at  once,  as  it  deteriorates  rapidly.  (To  be  pre- 
served carefully  in  a  small,  opaque  bottle  containing  not  more  than  50 
c.  c. :  "Pharm.  Helvetica,"  edit.  4.)  It  should  not  be  confounded  with 
ethylene  bromid  {q.  v.),  which  is  said  to  be  very  poisonous.  The  sp.  gr. 
of  ethylene  bromid  is  2.179,  while  that  of  ethyl  bromid  is  about  1.45. 

For  further  information  relating  to  the  employment  of  ethyl  bromid 
for  the  production  of  anesthesia  the  reader  is  referred  to  the  following 
literature : 

Abonyi :  "Das  Bromathyl  in  der  zahnarztlichen  Praxis,"  Yerh.  d.  X. 
Internal,  med.  Kongr.  zu  Berlin,  1890,  5  Abt.  14,  66.  "Ueber  Narkotika 
mit  besondere  Berucksichtigung  des  Bromathyls,"  Wiener  Klinik,  1891, 
No.  l;Zentram.  f.  Chir.,  1891,  319. 


740  :  ANESTHESIA 

Asch:   "tJber  Bromathyl,"  Therap.  Monatsheft,  1887,  54. 

von  Baracz :  "Beobachtungen  liber  die  Bromathylnarkose  in  der 
chirurigischen  Praxis  auf  Grund,  von  200  mit  dieseni  Mittel  ausgefiihr- 
ten  Narkosen,"  Wiener  Uin.  Woch.,  1892,  No.  26,  383.  "tjber  die 
Bromathylnarkose  auf  Grund,  von  200  eigenen  Beobachtungen/'  Nowy 
lelarsUe,  1891,  No.  6 ;  ZentralM.  f.  CUr.,  1892,  640. 

von  Bardeleben:  "Todesfall  in  Bromathylnarkose"  (Identisch  mit 
dem  von  A.  Koehler  beschriebenen),  Anlage  2  der  gurltschen  Statistik, 
YerJi.  d.  XXIII.  Deut  CUrurgenkongr.,  1894,  Teil  ii,  24. 

Billroth:  "Todesfall  in  der  Bromathylnarkose"  (Identisch  mit  dem 
von  Gleich  veroffentlichten  Fall.  Im  Bericht  falschlicherweise  der  Bill- 
roth-Mischung  zugeschrieben).  Anlage  4  zu  Gurltschen  Statistik.  Verli. 
d.  XXL  Deut.  Chirurgenkongr.,  1892,  Teil  ii,  325. 

Blumm :  "Stickstoffoxydul  oder  Bromathyl  als  Anasthetikum,"  Deut. 
Monats.  f.  Zahnheilh.,  1889,  25.  "Diskussion  zu  Hamecher"  (Polemisch 
gegen  A.  Witzel:  "Bromathyl  ist  kein  Herzgift"),  YerTi.  d.  LXII  Vers, 
deuts.  Naturf.  u.  Arzte  zu  Heidelberg,  1889,  673. 

Boennecken :  "Bericht  iiber  narkosen  mit  Aether  bromatus,"  Anlage 
4  der  Gurltschen  Statistik.  Verh.  d.  XXIII.  Deut.  Chirurgenhongr., 
1904,  Teil  ii,  31. 

Bonomeu  u.  Mazza:  "tJber  die  physiologische  Wirkung  des  Bromo- 
form,  des  Bromathyl  und  des  Bromiithylen,"  Selhsthericht  Zentralhl.  f. 
CUr.,  1884,  593. 

Bosscha :  "Die  Bromathylnarkose,"  "Haar  gescheedenis  en  haar 
toepassing  in  de  chirurgie."  Nederl.  Tijdschr.  v.  Geneeshurtde,  1894,  2, 
No.  24.    ZentralM.  f.  Cliir.,  1895,  277. 

Bourneville  et  Olliver:  "Eecherches  sur  Taction  physiologique  et 
therapeutique  du  bromure  d'ethyle  dans  I'epilepsie  et  I'hysterie,"  Gaz. 
med.  de  Paris,  13,  173 ;  Progres  med.,  1880  et  1881 ;  Deut.  Med.,  1880, 
349  u.  1881,  271. 

Boyals :  "De  I'emploi  du  bromure  d'ethyle  comme  anesthesique  pour 
I'operation  des  vegetations  adenoides  du  pharynx  nasal  chez  I'enfant." 
These,  Paris,  1890. 

Breitbach:  "Die  Bromathylnarkose,  praktische  Erfalirungen  mit 
15,032  Bromathylnarkosen."  XYI.  Internat.  Med.  Kongr.  in  Budapest, 
1909 ;  Separat  bei  Fr.  Tittel  Nachf.,  Dresden,  1911. 

Bruns :  "30  Bromathylnarkosen,"  Anlage  9  zu  Gurltschen  Statistik. 
Yerh.  d.  XXI.  Deut.  CUrurgenkongr.,  1892,  Teil  ii,  330.  "54  Broma- 
thylnarkosen," Anlarge  3  der  Gurltschen  Statistik,  Verh.  d.  XXII.  Deut. 
CUrurgenkongr. ,  1893,  Teil  ii,  26. 

Busch :  "47  Bromathylnarkosen,"  Anlage  4  der  Gurltschen  Statistik, 
Verh.  d.  XXII.  Deut.  CUrurgenkongr.,  1893,  Teil  ii,  26. 

Calmettes  et  Lubet :  Barbon,  "Nouveau  precede  pour  operer  les  vege- 
tations adenoides,"  Gaz.  hehd.,  Paris,  1890,  399, 


A   LIST    OF    ANESTHETICS  741 

Chaigneau:  "fitudes  comparatives  des  divers  agents  anesthesiques 
employes  dans  les  accouchements  natiirels."    These,  Paris,  1890. 

Challand :  "Bromathyl  kupiert  hysterische  Anf alle,"  Correspond,  f. 
schweizer  Aerzte,  1883,  649. 

Chisholm :  "Bromid  of  Ethyl,  the  Most  Perfect  Anesthetic  for  Short, 
Painful  Surgical  Operations,^'  1883 ;  Auszug  aus  dieser  Broschure  in  J. 
British  dent.  Association,  April,  1883.  See  Zentralhl.  f.  Chir.,  1883, 
313. 

Chudovszky:  "Morphium,  Atropin,  Bromathyl,  Sauerstoff,  Chloro- 
formnarkose,"  Ungaris.  Chirurgenkong.,  1911;  Zentralhl.  far  Chir., 
1912,  469. 

Clover:  "Bromid  of  .Ethyl  as  an  Anesthetic,"  Brit.  Med.  J.,  1880,  i, 
586. 

Cohn^  C. :  "Die  Entstehung  des  Knoblauchgeruches  bei  Anwendung 
des  Bromathers,"  Monats.  f.  Zahnheilk.,  1891,  9,  107.  "Die  Zersetzung 
des  Bromathers,"  Monats.  f.  Zahnheilk.,  1891,  9,  292. 

Cohn,  E. :  "Ueber  Anasthesierung  Kreissender,"  Deut.  med.  Woch., 
1886,  No.  16,  268. 

Cole :  "The  Physiological  Action  of  Ethyl  Bromide  and  Somno- 
form,"  Brit.  Med.  J.,  1903,  i,  1421. 

Desguinn:  "Les  nouveaux  anesthesiques,  le  bromure  d'ethyle." 
Archiv  med.  Beige,  1880,  277. 

Dischl :  "Lc  bromure  d'ethyle  comma  anesthesiqiie,"  Pittsburgh  Med. 
Rev.,  etc.,  1887,  360;  loc.  cit.,  Zit.  nach  L.  Fraenkel. 

Drakin :  "Zur  Frage  von  der  Anasthesie  durch  Bromathyl  in  der 
Zahnchirurgie,"  Nowosti  tierapii,  1889,  No.  38,  202,  hei  v.  Ziemacki, 
loc.  cit.,  730. 

Dreser:  "Zur  Pharmakologie  des  Bromathyls,"  Arch.  f.  exper.  Path. 
u.  Pharmak.,  1895,  36,  285. 

Dubrowin :  "Ein  Todesfall  bei  gemischter  Narkose,"  Chir.  Ann., 
1895,  342 ;  Zentralhl.  f.  Chir.,  1895,  1011. 

Ducasse :  "Essai  sur  I'emploi  du  bromure  d'ethyle  dans  les  accouche- 
ments naturels  simples,"  These,  Paris,  1883. 

Duval:  "Des  I'anesthesie  generale  par  les  inhalations  de  bromure 
d'ethyle,"  These,  Paris,  1880. 

Ebermann :  "Ueber  kombinierte  Bromathyl-Chlorof orm-Narkose,'' 
Wratsch,  1898,  Nos.  30-31.    Zentralhl.  f.  Chir.,  1898,  1095. 

Eschricht:  "Die  Bromathylnarkose,"  Deut.  med.  ^Yocll.,  1899,  No. 
31,  626.  "Bemerkungen  iiber  Bromathylnarkosen,"  Deut.  Monats.  f. 
Zahnheilk.,  1889,  299. 

Falk :  "Nebenwirkungen  und  Intoxikationen  bei  der  Anwendung 
neuerer  Arzneimittel,"  2  Bromathyl.  therap.  Monats.,  1890,  463. 

Fessler:  "Narkosen  mit  Bromather,  Aether  bromatus,"  Monats.  f. 
Zahnheilk.,  1891,  9,  179.    Miinch.  med.  ^Yoch.,  1890,  25. 


742  ANESTHESIA 

Fischer:  "Bromathylnarkose/'  Nordish  Tidslcrift  for  Terapie,  1, 
111.    ZentralU.  f.  Chir.,  1903,  1109. 

du  Fougeray:  "Note  sur  I'action  du  chloroforme  administre  a  tres 
petites  doses  apres  le  bronmre  d'ethyle,  etc."  Ann.  des  Malad.  de 
VOreilie,  22,  ?>m;  ZentralU.  f.  Chir.,  1897,  317. 

Fraenkel :  "Contribution  a  I'etude  du  broniure  d'ethyle  comme  anes- 
thesique  general,"  These,  Paris,  1894. 

Garin:  "Die  Bromathylnarkose  bei  Zahnextraktion,"  Wratsch,  1900, 
No.  31.    ZentralU.  /.  Chir.,  1900,  1307. 

Geza  Dieballa:  "Ueber  die  quantitative  Wirksamket  verschiedener 
Stoffe  der  Alkohol — und  Chloroformgruppe  auf  das  Froschherz,"  Archiv 
f.  exper.  Path.,  1894,  S^,  137. 

Gilles:  "Ueber  Bromathylnarkose,"  Deut.  Monais.  f.  Zahnheilk., 
1889,  271,  347;  "Beschreibung  einer  Bromathernarkose  nebst  weiteren 
Bemerkungen  zur  Bromathernakose,"  Deut.  Monats.  f.  Zahnheilk.,  1891, 
9,  Jt,  'Ueber  Bromathylnarkose,"  Berl.  Bin.  Woch.,  1892,  Nos.  8-9,  166, 
195. 

Givel :  "De  Femploi  du  broraure  d'ethyle  dans  les  accouchements 
naturels,"  Diss.,  Berne,  1881. 

Gleich:  "Ueber  Bromathylnarkosen,"  Wiener  klin.  Woch.,  1891, 
1002;  "Ein  Todesfall  nach  Bromathylnarkose,"  Wiener  klin.  Woch., 
1892,  No.  11,  167. 

Grunert :  "Die  Gefahrlichkeit  des  Bromiithers  ist  200mal  so  gross  als 
die  des  Stickoxyduls,"  Diskussionsbem.,  Gesellsch.  f.  Natur.  u.  Heilk.  zu 
Dresden,  30  Marz,  1913.    Mmich.  med  Woch.,  1912,  1404. 

Giinzberg:  "Ueber  Bromathyl,"  Med.  Kalenderj,  1891.  Ref.  bei  v. 
Ziemacki,  loc.  cit.,  731. 

Gurlt:  "Zur  Narkotisierungsstatistik,"  Yerh.  d.  XXIV  Deut. 
Chirurgenkongr.,  1895,  Teil  ii,  460. 

von  Hacker:  "25  Bromathylnarkosen,  Anlage  12  zu  Gurlts.  Sta- 
tistik."     Verh.  d.  XXI.  Deut.  Chirurgenkongr.,  1892,  Teil  ii,  331. 

Hackermann:  "Ueber  die  Anwendung  des  Bromathyls  zur  Narkose 
Kreissender"  Gesellsch.  f.  Gehurtsh.  u.  Gyndk.  zu  Berlin,  1883; 
ZentralU.  f.  Gyndkol.,  1883,  546. 

Hardy :  "Bromathylnarkose  in  der  Zahnheilkunde,"  Schweiz.  Viertel- 
jahrs.  f.  Zahnheilk.,  1898. 

Haffter :  "Die  Bromathylnarkose,"  Correspondenz-Blatt  f.  Schweizer 
Aerzte,  1890,  106,  143. 

Hagedorn:  "Zirka  100  Bromathylnarkosen,  Anlage  13  zu  Gurlts. 
Statistik."     Verh.  d.  XXI.  Deut.  Chirurgenkongr.,  1892,  Teil  ii,  332. 

Hahn :    "Die  Narkose  der  Chirurgie  und  Zahnheilkund,"  Diss.,  1896. 

Hammeeher:  "Ueber  Bromathylnarkosen,"  Deut.  Monats.  f.  Zahn- 
heilk., 1889,  7.  Verh.  d.  LXII.  Vers.  deut.  Natiiruf.  u.  Aerzte  zu  Heidel- 
berg, 1889,  668 ;  Korrespond.  f.  Zahndrzte,  1889,  343. 


A   LIST    OF    ANESTHETICS  743 

Hartmann  et  Bourbon :  "Le  bromure  d'ethyle  comme  anesthesique 
general,"  Rev.  de  Chir.,  1893,  13,  701. 

Haslebacher:  "Experimentelle  Beobachtungen  iiber  die  Nachwir- 
kungen  bei  der  Bromathyl.  und  Chlorathylnarkose,"  Diss.,  Berne,  1901. 

Heitmiiller :  "Empfehlung  des  Bromathers,"  DisTcussionshem. 
Gesellsch.  f.  Natur.  u.  Heilk.  zu  Dresden,  30  Miirz,  1912.  Milnch.  med. 
Woch.,  1912,  1403. 

Hennicke:  "Vergleichende  Untersuchungen  iiber  die  Gefahrlichkeit 
der  gebrauchlichten  Inhalationsanasthetika,"  Diss.,  Bonn,  1895. 

Hoddes :    "Ueber  Bromathernarkosen,"  Diss.,  Freiburg  i.  B.,  1892. 

Hollander :  "Das  Bromathyl  in  der  zahnarztlichen  Praxis,"  Verh.  d. 
X.  Internat.  med.  Kongr.  zu  Berlin,  1890,  5,  14,  57. 

Jendritza:  "Ein  Fall  von  Bromathylintoxikation/'  Therap.  Monats., 
1892,  152. 

Kappeler :  "Beitrage  zur  Lehre  von  dem  Anastheticis,"  Arch.  f.  hlin. 
Chir.,  1888,  37,  364;  Bromathyl,  376. 

Kocher :  "tjber  kombinierte  Chloroform- Ather-Narkose,"  Nachtrag : 
"Bromathyl-Ather-JSTarkose."  Korrespondenz-Blatt.  f.  Schweizer  Arzte, 
1890,  590.  -"Chirurgische  Operationslehre,"  1902.  Empfehlung  der 
Bromathyl- Ather-Narkose. 

Kohler :  "Zur  Bromathylnarkose,"  Freie  Verein.  d.  Chir.  Berlins,  2, 
1893;  Deut.  med.  Woch.,  1894,  Vereinsheilage,  7;  Zentralbl.  f.  Chir., 
1894,  41. 

Kolliker:  "tJber  die  Anwendung  der  Bromathylnarkose  in  der 
chirurgischen  Praxis,"  Zentralbl.  f.  Chir.,  1891,  385. 

Krecke:  "Beitrag  zur  ISTarkotisierungsfrage,"  Milnch.  med.  Woch., 
1894,  806.    Bromathyl. 

Kretschmann :  "Anwendung  des  Bromathyls  in  der  Ohrenkeil- 
kunde,"  Archiv  f.  Ohrenheilk.,  1889.  "Bericht  iiber  neuere  Mittel  in  der 
Ohrenheilkunde,"  Archiv  f.  Ohrenh.,  1889. 

Langgaard :    "tJber  Bromathyl,"  Therap.  Monat.,  1887,  62. 

Lanz :  "Bemerkung  zu  der  Mitteilung  von  Dr.  Otto  Zuckerkandl, 
TJber  eine  Modifikation  des  Chloroformiernes,"  Zentralbl.  f.  Chir.,  1891, 
969,  Bromathyl,  972. 

Larisch:    "1263  Bromathylnarkosen,"  Diss.,  Breslau,  1899. 

Laury:  "872  Bromathylnarkosen,  Anlage  24  zu  Gurlts.  Statistik." 
Yerh.  d.  XXI.  Deut.  Chir.,  1892,  Tail  ii,  350. 

Lebert :  "Des  accouchements  sans  douleur  ou  de  I'analgesie  obstetri- 
cale  par  le  bromure  d'ethyle,"  Rev.  med.  de  I'Est,  1882.  Deut.  Med.,  1882, 
250;  Archiv  de  Tocol.,  1882.    Ref.  bei  Givel,  1. 

Lepmann :  "Experimentelle  und  klinische  Untersuchungen  zur 
Frage  der  Bromathernarkosen,"  Berlin,  1895. 

Lesin :  "tJber  die  gemischte  Bromath}d-Chlorof orm-Xarkose,"  Y. 
Kongr.  Arzte,  St.  Petersburg,  1894.    Zentralbl.  f.  Chir.,  1894,  982, 


744  ANESTHESIA 

Levis :  "The  New  Anesthetic,  The  Bromid  of  Ethyl,"  Phila.  Med. 
Times,  1880,  188.     Virchow-Hirsch :  Jaliresler.,  1880,  454. 

Lewin:    "-Nebenwirkungen  der  Arzneimittel,"  Berlin,  1893. 

Lohers:  tJber  den  Einfluss  des  Bromathyls  auf  Atmung  und  Kreis- 
lauf,"  I>iss.^  Berlin,  1890.  "Sitzung  der  Phj^siol.  Gesellsch.  zu  Berlin," 
9.  Mai,  1890,  Zit.  Nach  Koclier.  ( Kaninchenversuche  mit  Bromathyl- 
narkose.) 

Lowenstein:  "Empfehlung  des  Bromathers  fiir  kurzdaurende  Nar- 
kosen."  Verein.  westd.  Hals.  Ohrendrzte  zu  Kolrv,  April,  1912,  21.  Med. 
Klinik,  1912,  1406. 

Lucas-Championniere :  "Diskussionsbem.  liber  Bromathyl  bei  Kreis- 
senden."  Bull,  de  la  Soc.  de  CUr.,  1880,  320 ;  Virchow-Hirsch,  1880,  1, 
454. 

Lustig:  "tJber  die  Anwendung  und  Wirkung  der  Anasthetika  und 
Narkotika  bei  Kindern,"  Yerli.  d.  XXIX.  Jahresver.  d.  zentral.  Dents. 
Zahndrzte,  1890.  Vgl.  dent.  Monats.  f.  Zahnheilh.,  1891,  355.  Auch 
iiber  die  Diskussion,  s.  bei  v.  Ziemacki,  loc.  cit.,  374-376. 

Magill :  "A  New  and  Eapid  Method  of  Anesthesia,"  N.  Y.  Med.  Rec, 
1893,  21;  Okt:  ZentralU.  f.  Chir.  1894,  750;  Internat.  Med.  Rec,  1894; 
Okt:    ZentralU.  f.  Chir.,  1895,  658. 

Malherbe :  "De  I'anesthesie  au  bromure  d'ethyle  dans  la  position  de 
Eose  pour  les  petites  operations  pratiquees  sur  les  voies  respiratoires  su- 
perieures,"  Rev.  hehd.  de  Laryngol.,  d'Etol.  et  de  Rhinol.,  1900,  Nr.  26. 
ZentralU.  f.  Chir.,  1901,  662. 

Mittenzweig:  "tJber  todliche  Nachwirkung  der  Bromathylnarkose," 
Zeitschr.  f.  Med.,  1890,  3,  40. 

Mittenzweig  und  Stahn:  "Experimenteller  Beitrag  zur  Vergiftung 
durch  Bromathyl,"  Zeitschr.  f.  Med.,  1890,  3,  373. 

Montgomery:  Am.  J.  of  Ohstet.,  1885,  561.  Eef.  bei  Haffter,  loc. 
cit.,  110.     "Bromathyl  in  der  Geburtshilfe." 

Moses:  Vereinig.  west.  Hals-  u.  Ohrendrzte  zu  Koln,  Apr.,  1912,  21, 
"Bromathylnarkose  der  Chlorathylnarkose  gleichwertig  fiir  Tonsil- 
lotomien,"  Med.  Klinik,  1912,  1685. 

Miiller,  B. :  "Tiber  Fettmetamorphose  in  den  inneren  parenchy- 
matosen  lebenswichtigen  Organen  nach  einfachen  und  Mischnarkosen," 
Arch.  f.  Uin.  Chir.,  1905,  75,  896. 

Muller,  B. :  "tJber  die  Anwendung  des  Bromathyls  in  der  Geburt- 
shilfe,"  Berl.  Uin.  Woch.,  1883,  673. 

Napalkow:  "Zur  Frage  der  kombinierten  Bromathyl-Chloroform- 
Narkose,"  Chir.,  Aug.,  1902;  Zentralbl.  f.  Chir.,  1903,  263. 

Norton:  "Bromide  of  Ethyl  as  an  Anesthetic,"  Brit.  Med.  J.,  1880, 
2,  535;  "New  Forms  of  Anesthetics,"  Brit.  Med.  Assn.,  1865.  Nun- 
neley:    Brit.  Med.  J.,  1865,^,  192. 

Osterlen:  "Bromathyl,"  Korrespond.  f.  Zahndrzte,  1^89. 


A   LIST    OF    ANESTHETICS  745 

Pauschinger :  "Bromiithyl/'  Milncliener  med.  Woch.,  1887.  Nr.  30, 
568. 

Petsch :  "Das  Bromathyl  unci  seine  Verwendung  als  Anasthetikum/' 
Deut.  Monats.  /.  ZalmheWc,  1888,  471. 

Phillips:  "Ethylbromid  in  Ophthalmic  Surgery,"  Phil.  Med.  and 
Surg.  Rep.,  Feb.  5,  1887,  177. 

Pomeranzew:  "Charakteristik  des  Bromathyls  in  bczug  auf  die 
Gefar  seine  Anwendung  als  Anasthetikum,"  Cliirurgia,  Eussisch,  1897, 
S.  1.    ZentralU.  f.  CUr.,  1897,  462. 

Eabuteau:  Compt.  rend,  de  la  8oc.  de  Biol.,  1876,  28,  49;  M. 
Fraenkel:  Loc.  cit.  "Eecherches  sur  les  proprietes  physiologiques  et  la 
mode  de  I'administration  de  I'ether  bromhydrique,"  Compt.  rendu,  de 
I'Acad.  des  Sciences,  1876,  55,  1394;  Virchow-Hirsch :  Jaliresher.,  1876, 
i,  415 ;  Fraenkel :  Loc.  cit.  "Eecherches  sur  les  proprietes  physiologiques 
et  la  mode  d'elimination  de  I'ether  bromhydrique,"  Gaz.  des  Hop.,  1877, 
50.  "Eecherches  sur  les  proprietes  physiologiques  et  la  mode  d'elimina- 
tion du  bromure  d'ethyle ;  usage  de  cet  ether ;  son  action  sur  la  germina- 
tion et  la  vegetation,"  Mem.  communique  a  la  Soc.  de  Biol.  Gaz.  med. 
de  Paris,  1880,  334,  385  et  411;  Virchow-Hirsch:  Jaliresher.,  1880,  i, 
455. 

Eegli:  "Eperimentelle  Beitrage  zur  Kenntnis  der  Wirkung  des 
Bromathyls  auf  Herz  und  ISTieren,"  Diss.,  Berne,  1892. 

Eeich:  "tjber  Bromather  und  kombinierte  (sukzessive)  Bromather- 
Chloroform-Karkose,"  Wiener  med.'  WocJi.,  1893,  No.  23  u.  28,  993, 
1046,  1090,  1141,  1178  u.  1224. 

Eein:  "tJber  die  Mischnarkose  von  Bromathyl  und  Chloroform," 
Chirurgie  5,  530;  ZentralU.  f.  CUr.,  1900,  638. 

Eichelot:  "Bromathyl-Chloroform-ISrarkose,"  Bull,  de  VAcad.  de 
Med.,  1902,  ^7,  179. 

Eitter:  "478  Bromathylnarkosen,"  Anlage  30  zu  gurlts.  Statistik. 
Verli.  f.  XXI.  Deut.  Chirurgenkongr.,  1892,  Teil  ii,  355.  "406  Brom- 
athylnarkosen," Anlage  12  zu  Gurlts.  Statistik.  Verh.  d.  XXII.  Deut. 
Chirurgenkongr.,  1893,  Teil  ii,  38.  "Bericht  iiber  weitere  335  Brom- 
athylnarkosen," Anlage  29  der  Gurltschen  Statistik.  Yerh.  XXIV.  Deut. 
Chirurgenkongr.,  1895,  Teil  ii,  519.  "Bericht  liber  1365  Bromathyl- 
narkosen," Anlage  21  der  Gurltschen  Statistik.  Verh.  d.  XXIII.  Deut. 
Chirurgenkongr.,  1894,  Teil  ii,  54. 

Eoberts:  "Case  of  Death  Occurring  During  the  Administration  of 
Bromid  of  Ethyl,"  Phila.  Med.  Times,  July  17,  1880.  ZentralU.  f.  CUr., 
1880,  639. 

Eobin:  "Note  sur  un  nouvel  agent  anesthesique,  I'ether  bromhy- 
drique," Compt.  rendu,  de  VAcad.  des  Sci.,  Paris,  1851,  32,  649. 

Eose:  "Diskussion  iiber  Bromathylnarkose,"  Gesell.  f.  Gehurtsh.  u. 
Gyndkol.  zu  Berlin,  1883 ;  ZentralU.  f.  Gyndkol.,  1883,  546. 


746  ANESTHESIA 

Eoth :  "tJber  Brom-Ather-j^arkose/'  Prager  med.  Woch.,  1906,  No. 
21 ;  Z entrain,  f.  Chir.,  1907,  1048. 

Salzer :  "Einige  Worte  iiber  Narkose  im  Dienste  der  Zahnheil- 
kmide,"  Pest,  med.-chir.  Presse,  1893,  No.  33 ;  Zentralbl.  f.  Chir.,  1893, 
853. 

Scliede:  "149  Eromiithylnarkosen,"  Anlage  31  zu  Gurlts.  Statistik. 
Verh.  d.  XXI.  Deut.  Cliirurgenlongr.,  1893,  Teil  ii,  360. 

Scheps:  "Das  Bromathyl  und  seine  Verwendbarkeit  bei  zahnarztli- 
chen  Operationen,"  Diss.,  Breslau,  1887. 

Schneider :  "tJber  das  Wesen  der  Narkose  im  allgemeinen,  mit  be- 
sonderer  Beriicksichtigung  der  Bromathernarkose,'^  Deut.  Monat.  f. 
Zahnheilk.,  1890,  8,  170  u.  217;  von  Ziemacki:  Arch.  f.  hlin.  Chir., 
1891,  42,  732.  "Das  Bromathyl  in  der  zahnarztlichen  Praxis,"  Verh.  d. 
X.  Internat.  med.  Kongr.  zu  Berlin,  1890,  Bd.  5,  Abt.  14,  66.  Vgl. 
Deut.  Monat.  f.  Zahnheilk.,  1890,  Nos.  8-10. 

Schroeder :  "Ein  neuer  Betaubungsapparat  fiir  Bromather,"  Monats. 
f.  Zahnheilk.,  1891,  9,  513. 

Schwartzkoph :  "Erfahrungen  mit  Bromathylnarkosen,"  Diskus- 
sionsbemerkung.    Deut.  Monats.  f.  Zahnheilk.,  1889,  350. 

Segond:  "Sur  I'anesthesie  combinee  avec  le  bromure  d'ethyle  et  le 
chloroforme,"  Bull,  et  Mem.  de  la  Soc.  de  Chir.  de  Paris,  20,  39 ;  Zen- 
tralbl. f.  Chir.,  1895,  659. 

Sims :  "The  Bromid  of  Ethyl  as  an  Anesthetic,"  N.  Y.  Med.  Rec, 
1880,  361;  Virchow-Hirsch :  Jahresher.,  1880,  50,  454;  Vgl.  audi  Zen- 
tralbl. f.  Chir.,  1880,  714;  N.  Y.  Med.  J.,  1880,  32,  176.  Zentralbl.  f. 
Chir.,  1880,  714. 

Sowers :  "Ethyl  Bromid,  or  Hydrobromic  Ether ;  Cases  Operated  on 
under  Its  Influence,"  Phila.  Med.  and  Sur.  Rep.,  1880,  93;  Virchow- 
Hirsch  :    Jahresber.,  1880,  454. 

Sternfeld:  "ttber  Bromath}^  und  seine  Verwendung  in  der  arzt- 
lichen  Praxis,"  Miinch.  med.  Woch.,  1890,  No.  1415,  351,  267. 

Szuman :  "Das  Bromathyl  und  die  Bromathyl-narkose,"  Therap. 
Monats.,  1888,  155  u.  226 ;  Zentralbl.  f.  Chir.,  1888.  "Uber  Bromathyl 
und  die  Gefahren  der  Bromathylennarkose,"  Gaz.  Lekarska,  1890,  No. 
36 ;  Zentralbl.  f.  Chir.,  1890,  1024. 

Terrier:  "Sur  I'anesthesie  combinee  par  le  bromure  d'ethyle  et  le 
chloroforme,"  Bull,  et  Mem.  de  la  Soc.  de  Chir.  de  Paris,  20,  400.  Zen- 
tralbl.f.  Chir.,  1895,  658. 

Terrier  et  Peraire:  "Manuel  de  I'anesthesie  chirurgicale,"  Paris, 
1894. 

Terrillon :  "Anesthesie  locale  et  generale  par  le  bromure  d'ethyle," 
Compt.  rendu,  1880,  91,  1170.  Virchow-Hirsch:  Jahresbericht,  1880, 
1,  454-455;  Gaz.  med.  de  Paris,  1880,  No.  22;  Zentralbl.  f.  Chir.,  1880, 
500.    "De  I'anesthesie  generale  par  le  bromure  d'ethyle,"  Bull.  Gen  do 


A   LIST    OF    ANESTHETICS  747 

therap.,  1880,  300;  loc.  cit.,  Bull,  de  la  Soc.  de  Chir.,  1880,  316  et  320. 
''Diskussion  iiber  Bromathyl,"  8oc.  de  Chir.  de  Paris;  Bull  de  Therap., 

1881,  337. 

Thiem :  "Diskussionsbemerkung  betreffend  Bromathyl-narkose," 
Verh.  d.  XIX.  Deut.  Chirurgcnkongr.,  1890,  Tcil  i,  14. 

Tschunichin :  "Bromathyl  in  der  geburtschilflichen  Praxis," 
Wratsch,  1885,  No.  30 ;  von  Ziemacki :    Loc.  cit.,  730. 

Turnbull:  "Advantages  and  Accidents  of  Artificial  Anesthesia," 
Phila.,  1879.  Virchow-Hirsch :  Jahresher.,  1880,  1,  454.  "Artificial 
Anesthesia,  A  Manual  of  Anesthetic  Agents,  and  Their  Employment  in 
the  Treatment  of  Disease."  Philadelphia,  1891,  P.  Blakiston's  Son  & 
Company. 

Vajna:  "Bromathylmaske,"  Anlage  18  zu  Gurlts.  Statistik.  Verh.  d. 
XXII.  Deut.  Chirurgenkongr.,  1893,  Teil  ii,  43. 

Veit :  "Bromathyl  bei  Kreissenden,"  Dishussion  in  der  Gesellsch.  f. 
Gehurtsh.  u.  Gynah.  zu  Berlin,  1883;  Zentralhl.  f.  Gynak.,  1883,  547. 

Villeneuve :  "Sur  I'anesthesie  combinee  par  le  bromure  d'ethyle  et  le 
chloroforme,"  Bull,  et  Mem.  de  la  Soc.  de  Chir.  de  Paris,  20,  418;  Zen- 
tralhl. f.  Chir.,  1895,  659. 

Vutzeys:  Bull,  de  I'Acad.  roy.  de  Belgique,  1876;  Zit.  naeh  M. 
Fraenkel,  loc.  cit.,  9. 

WalkhofP:  "Todesfall  dureh  Bromather,"  Monats.  f.  Zahnheilh., 
1891,  9,  517. 

Wessler :  "Skandinavisk  Tidskrift  for  Tandlakara,  1889,"  Edition  4. 
von  Ziemacki :  Loc.  cit.,  734  (41  Bromathylnarkosen  mit  durchschnitt- 
lich  5  g.). 

Wiedemann :  "tJber  das  Hydrobromathyl  als  Anasthetikum  am 
Kreissbett,"  >S'^.  Petersburger  med.  Woch.,  1883. 

Wietland:  "Die  Narkosen  im  Easier  Kinderspital,"  Correspondenz- 
Blatt  f.  schweizer  Arzte,  1894,  564  u.  597. 

Wilcox :  "Bromide  of  Ethyl  as  an  Anesthetic,"  Annals  of  Surg.,  1891, 
No.  4;  Zentralhl.  f.  Chir.,  1891,  1000. 

Willemer:  "64  Bromathylnarkosen,"  Anlage  37  zu  Gurlts.  Statistik. 
Yerh.  d.  XXI.  Deut.  Chirurgenkongr.,  1892,  Teil  ii,  365. 

Williams :  "Bromide  of  Ethyl  as  an  Anaesthetic  for  Short  Opera- 
tions and  as  a  Percursor  to  the  Administration  of  Ether,"  Brit.  Med.  J., 

1882,  1,  402. 

Witzel,  A.  "tJber  den  Gebrauch  des  Schlafgases  in  der  zahnarzt- 
lichen  Praxis"  ( Gef ahrlichkeit  des  Bromathyls:  vgl.  10).  Deut.  Zahii- 
heilkunde  in  Vortrdgen,  1889,  Nos.  5-6,  Hagen  i.  W.,  H.  Riesel  &  Co. 

Witzel,  J. :  "Bericht  iiber  465  Bromathernarkosen,"  Monats.  f.  Zahn- 
heilh., 1891,  9,  421. 

Witzel,  0. :  "Wie  sollen  wirk  Narkotisieren,"  Miinch.  med.  Woch., 
1902,  1903. 


748  ANESTHESIA 

Wood:  "The  Physiological  Action  of  Ethyl-Chlorid  and  Ethyl- 
Bromid/'  Phil.  Med.  Times,  1880,  370;  Virchow-Hirsch :  Jahresher., 
1880, 1.  455. 

V.  Ziemacki:  "Bromathyl  in  der  Chirurgie,"  Arcli.  f.  hlin.  Gliir., 
1891,  'Jk2,  717. 

Zimmer :  "Mahnung  ziir  Vorsiclit  mit  Bromather  auf  Grand  zweier 
nich  niiher  mitgeteilter  Todesfalle  in  Berlin,"  Diskussionsbemerkung. 
Monats.  f.  Zalinlieilh.,  1891,  9,  518. 

Ethyl  Chlorid. — Monochlorethane  is  well  known  as  an  anesthetic 
(Heyfelder,  1848;  Nunneley,  1849;  Snow  and  Eichardson,  1852.)  See 
Chapter  VI. 

See  Kelene,  Antidolorin,  Loco-Dolor,  and  EtJiylol. 

Ethyl  Chlorid  Bengue. — A  purified  ethyl  chlorid. 

Ethyl  Chlorid  C.  P. — A  "chemically  pure"  ethyl  chlorid,  for  both 
local  and  general  anesthesia. 

Ethyl  Chlorid  Polychlorated. — This  mixture  of  chlorinated  ethyl 
chlorids,  principally  tri-,  tetra-,  and  penta-chlorethane,  is  also  known 
as  "Wiggers'  anesthetic  ether"  and  as  "polychlorated  hydrochloric 
ether." 

Ethyl  Ether.— See  Chapter  V. 

Ethyl  ether  (1  ounce)  containing  camphor  (4  drachms)  was  used 
as  a  local  anesthetic  quite  extensively  about  1875. 

Ethyl  Ether-Chloroform  Mixtures. — On  the  production  of  narcosis 
with  a  mixture  of  1  volume  of  chloroform  and  5  to  6  volumes  of  ethyl 
ether,  see  Kionka:  Jalireslurse  f.  arztl.  Forthildung,  1910,  No.  8,  3. 

Ethyl  Formate. — Byasson  experimented  upon  the  lower  animals 
with  formic  ether.  He  supposed  that  it  was  decomposed  in  the  blood 
into  alcohol  and  alkaline  formates.  Inhalation  of  its  vapor  lowered  the 
temperature  as  much  as  3.5°  C,  caused  muscular  relaxation  and  anes- 
thesia, with  some  degree  of  asphyxia.  Its  effects  resembled  those  pro- 
duced by  chloral  hydrate  rather  than  the  effects  of  an  ether.  Upon  the 
human  subject,  the  use  of  6  or  8  grams  only  caused  drowsiness,  with- 
out any  other  symptom. 

Ethyl  Hydrid.— Eichardson  {Sci.  Am.  Suppl.,  No.  515,  8228)  stated 
that  the  physiological  action  of  this  gas  was  generally  the  same  as  for 
amyl  hydrid  {q.  v.)  ;  and  that  its  anesthetic  value  was  also  practically 
the  same,  but  less  manageable,  owing  to  its  being  a  gas.  It  was  Eich- 
ardson who  introduced  ethyl  hydrid  in  1867. 

Ethyl  lodid. — Hydriodic  ether  (mono-iodoethane)  decomposes  quite 
rapidly  even  in  diffused  daylight,  the  light  liberating  iodin  which  colors 
the  ether;  the  decomposition  is  very  slow  in  the  dark,  and  may  be 
rendered  still  slower  by  the  addition  of  a  very  dilute  solution  of  soda. 
It  may  also  be  kept  in  contact  with  a  small  amount  of  mercury.     Ethyl 


A   LIST   OF    ANESTHETICS  749 

iodid  has  been  considered  unsuitable  for  clinical  purposes,  owing  to  its 
unpleasant  taste  and  its  volatility  (b.  p.,  -\-  70-75°  C).  It  acts  like 
chloroform,  but  anesthesia  comes  on  slowly  and  is  more  permanent. 

On  the  physiological  action  of  ethyl  iodid,  see  Webster:  Bio-Chem. 
J.,  1906,  1,  328. 

Ethyl  Nitrate. — Simpson  (1848)  found  that  "nitric  ether"  was  a 
rapid  and  powerful  anesthetic,  but  the  subsequent  headaches  and  dis- 
agreeable after-effects  were  of  so  serious  a  nature  as  to  condemn  it. 
Fifty  or  sixty  drops  were  inhaled. 

Ethly  Nitrite. — "Nitrous  ether"  was  tried  by  the  Committee  of  the 
British  Medical  Association,  which  reported  that  it  produced  "great 
excitement  and  convulsions,  almost  immediately  followed  by  cessation 
of  respiration." 

Ethyl-o-Anisidin  Formate. — Found  by  Goldschmidt  {Chem.  Ztg., 
25,  329)  to  be  a  strong  local  anesthetic.  Goldschmidt  (Eng.  Pat.  9792, 
1898)  has  also  claimed  the  manufacture  of  compounds  of  orthoformic 
ester  with  o-  and  p-phenetidin  and  anisidin,  for  use  as  anesthetics. 

Ethylene  Chlorid.— S-Dichlorethane,  CH0CI.CH2CI  ("dutch  liquid" ; 
elayl  chlorid),  has  been  employed  as  a  general  anesthetic  instead  of 
chloroform,  especially  in  ophthalmic  surgery.  Its  anesthetic  action 
was  first  studied  by  Simpson  in  1846,  Snow  in  1848,  Clover  in  1848, 
and  Eichardson  in  1851.  The  latter  {Sci.  Am.  SuppL,  'No.  515,  8228) 
regarded  it  as  a  good  anesthetic,  very  much  like  chloroform  in  its  action, 
although  less  rapid.  He  pointed  out  that  the  vapor  was  pleasant  to 
inhale;  that  the  quantity  required  for  complete  anesthesia  was  2  to  8 
fluid  drachms;  that  the  required  amount  of  air  by  vapor  was  5  to  10 
per  cent;  that  the  stages  were  induced  slowly,  with  a  rather  long  spas- 
modic period ;  and  that  recovery  was  slow,  with,  in  rare  cases,  vomiting. 
It  "deserves  more  experimental  study." 

Macleve  (Chem.  News,  4-1,  154)  used  a  mixture  of  ethylene  chlorid 
and  nitrous  oxid.  Eeichert  (Phila.  Med.  Times,  11,  518)  found  that 
ethylene  chlorid  (?)  caused  anesthesia  with  the  usual  stages,  and  that, 
like  chloroform,  it  depressed  the  heart  and  steadily  lowered  arterial 
pressiire. 

The  ethylene  chlorid  on  the  market  is  a  colorless,  oily  liquid,  which 
possesses  a  density  of  1.265  at  -f-  15°  C,  and  a  boiling  point  of  -|-  83° 
C;  it  has  a  pleasant  odor  and  sweet  taste,  but  the  vapor  is  irritating; 
it  is  soluble  in  alcohol,  ether,  chloroform,  and  slightly  soluble  in  water. 
It  is  said  to  have  a  similar  action  to  chloroform,  and  to  have  found 
extensive  use  as  a  chloroform  substitute. 

See  Wallace:  Brit.  Med.  J.,  1910,  1288. 

Ethylene  (Monochloro-)  Chlorid.— This  anesthetic,  called  also  mono- 
chlorethylene  chlorid,  monochlorinated  dutch  liquid,  and  vinyl  tri- 
chlorid,  has  been  said  to  be  superior  to  chloroform  and  ethylene  chlor- 


750  ANESTHESIA 

id.  The  preparation  now  on  the  market  is  prepared  from  vinyl  chlor- 
id  by  the  action  of  antimony  pentachlorid ;  it  is  a  colorless  liquid  with 
a  pleasant  odor,  boiling  at  +  114°  C,  and  having  a  density  of  1.458 
at  +9°  C.  Taube  (Am.  J.  Pharm.,  1880,  603;  1881,  119)  showed 
the  availability  of  monochlorethylidene  and  monochlorethylene  chlorids 
as  anesthetics. 

Ethylene  Dibromid. — S-Dibromethane  (CHoBr.CHaBr)  is  a  color- 
less, volatile,  emulsifiable  liquid,  possessing  a  chloroform-like  odor.  The 
density  of  the  product  on  the  market  is  3.189  at  -]-  15°  C,  and  it  boils 
at  +  139-131°  C.  It  is  miscible  in  all  .proportions  with  alcohol,  but  is 
insoluble  in  water.  Ethylene  dibromid  is  a  cardiac  poison  and  its  anes- 
thetic action  is  slight.  Scherbatschetf  (Arch.  exp.  Path.  u.  Pliarm., 
1903,  47)  found  that  ethylene  bromid  is  not  a  true  anesthetic  in  lower 
animals.  It  is  probable  that  some  of  the  evil  effects  produced  in  the 
early  use  of  ethyl  hromid  (q.  v.)  were  due  to  the  presence  of  ethylene 
bromid  in  the  preparations  then  in  use. 

Ethylidene  Chlorid  (Chlorinated  muriatic  ether;  a-dichlorethane ; 
ethidene  bichlorid;  chloridene;  Aran's  ether). — This  compound  is  used 
instead  of  chloroform  for  minor  operations,  producing  rapid  narcosis  of 
short  duration.  Ethylidene  chlorid  was  apparently  first  used  by  Snow 
(see  "On  Anesthetics"  p.  33)  in  1851.  Richardson  states  (Sci.  Am. 
Supply  No.  515,  8338)  that  "Snow,  who  introduced  this  anesthetic,  and 
who  was  seized  with  his  first  fatal  attack  while  writing  upon  it,  told  me 
he  estimated  its  value  as  equal  to  chloroform,  an  estimate  which  has 
been  sustained  by  later  experience.  The  anesthetic  has,  however,  more 
than  once  proved  fatal,  apparently  from  failure  of  the  circulation,  al- 
though in  my  own  experiments  with  it  on  lower  animals  I  once  restored 
a  rabbit  to  life  by  artificial  respiration  seven  minutes  after  the  natural 
respiration  had  ceased."  Eichardson  found  the  vapor  of  "ethene  di- 
chlorid"  pleasant  to  breathe;  that  the  quantity  required  for  complete 
anesthesia  was  3  to  8  drachms;  and  the  required  charge  of  air  by  vapor 
was  from  5  to  10  per  cent.  Anesthesia  was  found  to  be  produced  rather 
more  rapidly  than  by  chloroform,  with  the  second  or  spasmodic  stage 
sometimes  acute;  but  recovery  was  easy,  with  no  important  after-efi'ects, 
and  vomiting  was  a  less  frequent  accompaniment  than  after  chloroform. 

Binz  (Med.  Times  and  Gaz.,  1879,  1)  produced  human  anesthesia 
by  means  of  ethylidene  chlorid  and  thought  it  increased  the  force  of 
circulation;  but  Eeeve  ("New  Remedies,"  1880,  334)  found  that  it 
lowers  arterial  pressure,  although  it  does  not  suddenly  paralyze  the 
heart.  See,  also,  Clover:  Brit.  Med.  J.,  May  39,  1880,  797;  and  Comm. 
Rep.,  idem,  Jan.  4,  1879. 

The  ethylidene  chlorid  on  the  market  is  a  colorless,  oily  liquid,  pos- 
sessing the  odor  and  taste  of  chloroform;  it  has  a  density  of  1.178  at 


A  LIST   OF    ANESTHETICS 


751 


-|-  15°  C.,  and  boils  at  -\-  58-G0°  C.  That  used  by  Eichardson  possessed 
a  density  of  1.174  and  a  boiling  point  of  -|-  64°  C. ;  it  was  undoubtedly 
lacking  in  purity,  and  it  would  be  of  value  to  thoroughly  study  the 
physiological  action  of  this  compound,  using  the  pure  preparation. 

See  /Ether  Anwstheticus  Aranii. 

Ethylol. — A  purified  ethyl  chlorid  of  German  manufacture. 

Eucain-A. — "Alpha-eucain"  is  the  hydrochlorid  of.benzoyl-n-methyl- 
tetramethyl-gamma-oxypiperidin  carboxylic  methyl  ester,  CigHgyNO^. 
HCl.HoO.     It  was  also  termed  eucainae  hydrochloras,   since  eucain-A 


O.COCeHj 


COOCH3 


CH,, 


(or  alpha-eucain),  is  properly  the  base,  of  which  eucain-A,  so-called,  is 
the  hydrochlorid.  The  preparation  on  the  market  in  1896  formed 
colorless  crystals  and  was  soluble  in  about  10  parts  of  water.  Its  solu- 
tion was  sterilizable  by  boiling 

The  base  eucain-A  is  constitutionally  closely  allied  to  cocain,  and,  like 
the  latter,  is  a  local  anesthetic;  it  is,  however,  cheaper  than  cocain. 
Gaetono  Vinci  (Berl.  klin.  Wocli.,  1896,  No.  27)  found  that,  in  the 
case  of  the  eye,  anesthesia  resulted  in  2  to  5  minutes  after  the  applica- 
tion of  a  2  per  cent  water  solution,  while  its  influence  lasted  from  10  to 
15  minutes.  Its  application  was  said  to  cause  neither  mydriasis  nor 
paresis  of  accommodation — it  did  not  act  on  the  pupil  or  contract  the 
arterioles — but  to  produce  a  slight  hyperemia  of  the  mucous  membrane. 

A  number  of  writers  have  expressed  themselves  on  the  properties  of 
eucain-A,  namely: 

Kiesel:    Zahndrztl.  Rundschau,  1896,  No.  196. 

Wolff :   Zahndrztl.  Woch.,  1896,  No.  472. 

Berger :    Rev.  de  therap.  med.  chir.,  1896,  355. 

Vollert:    Munch,  med.   Woch.,  1896,  Nos.  22  and  37. 

Gorl:    Therap.  Monatsh.,  1896,  No.  7,  378. 

Deneffe:    Le  Scalpel,  Sept.  13,  1896,  No.  11. 


752  ANESTHESIA 

Fuller:   Internat.  J.  of  Surg.,  1896,  No.  9. 

Forster:    Langsdale's  Lancet,  August,  1896. 

de  Mets :    Belg.  mcd.,  1896,  No.  43. 

Legueu:    Presse  medicale,  1896,  No.  88. 

Vinci:     Virchows  Archiv,  IJ^S,  78;   Therap.  Monatsh.,   1896,  330. 

Carter:'  Pharm.  J.,  1896,  No.  1360. 
■    Zwillinger:   Pest.  med.  cliir.  Presse,  1896,  Nos.  44  and  45. 

Best:    Deut.  med.  Woch.,  Sept.  3,  1896,  573. 

Vogt :    Bull.  Gen.  de  Therap.,  1897,  112. 

Bocquillon:    J.  med.,  Paris,  1897,  No.  37. 

Eeclus :    La  France  Med.,  1897,  No.  8. 

These  journal  contributors  seemed  to  be  favorably  impressed  with 
eucain-A  on  the  whole  and  regarded  it  as  a  suitable  substitute  for  cocain, 
although  Vollert,  Zwillinger,  and  Best  drew  attention  to  the  irritating 
action,  which  was  so  considerable  that  even  a  1  per  cent  solution  caused 
a  sensation  of  pain  and  burning.  Vollert  {loc.  dt.),  as  well  as  Wiiste- 
feld  {Miinch.  med.  Wocli.,  1896,  No.  51),  also  observed  that  mydriasis 
and  accommodation  were  affected,  but  not  in  the  same  degree  as  by 
cocain;  they  also  objected  to  the  destructive  action  on  the  epithelium  of 
the  cornea  and  conjunctiva.  Deneffe  noticed  that  eucain-A  hardened  the 
tissue  to  such  an  extent  as  to  make  it  difficult  to  introduce  a  suture 
needle  through  it. 

In  1897  there  were  two  varieties  of  eucain  on  the  market,  viz.: 
Eucain-A  and  Eucain-B  (q.  v.).  Schmitt  ("Nouveaux  remedes,"  1897, 
353)  pointed  out  that  eucain-B  was  superior  to  eucain-A,  inasmuch  as 
it  was  3  to  3  times  less  toxic.  Eucain-A  was,  in  1897,  prescribed  in  the 
form  of  an  ointment  for  producing  anesthesia  on  mucous  membranes, 
and  in  painful  wounds,  and  for  itching  piles,  pruritus  ani,  and  pruritus 
pudendorum  {Therap.  Monatsh.,  1897,  No.  2,  127) ;  and  the  majority 
of  the  clinical  observations  published  during  this  year  related  to  eu- 
cain-A, while  it  was  ascertained  that  eucain-B  was  particularly  suitable 
for  ophthalmic  operations. 

For  experimental  data  relating  to  the  physiological  action  of  eucain, 
as  compared  with  that  of  cocain,  consult  the  following  contributions  on 
the  subject: 

Pouchet:  Nouveaux  remedes,  1897,  169;  J.  de  med.  de  Paris,  1897, 
No.  10. 

Von  Eecke:    Belgique  med.,  1897,  No.  790. 

Charteris :     Brit.  Med.  J.,  1897,  No.  1891. 

Noel :    Sem.  med.,  1897,  No.  26,  210. 

Vinci :    Virchows  Archiv,  1897,  No.  2,  145. 

Schmitt :    Nouveaux  remedes,  1897,  No.  12,  353. 

Hobday:    Brit.  Med.  J.,  1897,  No.  1901. 

Legrand :    Nouveaux  remedes,  1897,  161. 


A   LIST    OF    ANESTHETICS 


753 


On  the  therapeutic  application  of  eucain-A,  see  Keclus-IIernette: 
Nouveaux  remedes,  1897,  172. 

On  the  employment  of  eucain-A  in  surgery,  see  the  following  papers : 

Home:    Brit.  Med.  J.,  Nov.  27,  1S97. 

Hernette:    T/?,e56!,  Paris,  1897. 

Legrand:    Nouveaux  remedes,  I'^'d^,  IQl. 

Jarrow:    Med.  Eec,  1897,  49. 

Legueu  and  Lihou:    Presse  med.,  1897,  No.  15,  80. 

Lohmann:  Therap.  Monatsh.,  1897,  427. 

Legueu  and  Lehuell:     Gaz.  des  Hop.,  1897,  No.  19,  20. 

Heinze :    Vircliows  Arcliiv,  1898,  466. 

Eeclus:     Therap.  Woch.,  1897,  No.  8,  191. 

Hackenbruch:  "Oertliclie  Schmerzlosigheit  bei  Operationen," 
Wiesbaden,  1897. 

Spencer:  Univ.  Med.  Mag.,  Nov.,  1896;  Med.  and  Surg.  Rep., 
Nov.  28,  1896. 

These  contributions,  together  with  many  others  on  the  bearing  of 
eucain  in  ophthalmic  surgery,  rhino-laryngology,  and  otology,  dental 
surgery,  and  in  the  treatment  of  urethral  diseases,  showed  that  eucain-A, 
or  rather  the  eucains,  are  endowed  with  considerable  anesthetic  power. 
Eucain-A  was  objected  to,  especially  by  ophthalmic  surgeons,  particu- 
larly because  it  produced  a  slight  irritation  on  the  mucous  membrane; 
and  it  may  be  said  that  it  was  practically  discontinued  on  the  introduc- 
tion of  eucain-B  {q.  v.).  Moreover,  eucain-A  is  more  toxic  than  eu- 
cain-B  in  the  proportion  of  about  four  to  one. 

Eucain-B. — "Beta-eucain,"  beta-eucain  hydrochlorate,  2,  6,  6-tri- 
methyl-4-benzoxy-piperidin  hydrochlorid,  or  benzoyl-vinyl-diacetone- 
alkamin  hydrochlorid. 


CH3 


-CH 


NH.HCl 


CH3 


-CHo 


CH.OcCGCeHe) 


CH2 


CH„ 

or  C5He.C7H50o.CH3.NH(CH3)oHCl,  is  a  white  crystalline  powder  pos- 
sessing the  following  solubilities  at  ordinary  temperatures : 

In  wate  • 3.5  per  cent. 

In  alcohol 3.5    "      " 

In  chloroform 15.0    "      " 

In  glycerin 2.0    "      " 


764  ANESTHESIA 

One  part  of  beta-eucain  hydrochloric!  is  soluble  in  5  parts  each  of 
anilin  and  alcohol,  and  is  insoluble  in  olive  oil  and  paraffin  oil  alone,  or 
in  ethyl  ether  in  material  amounts.  Suspensions  with  lanolin  and  the 
heavy  mineral  oils  may  be  prepared  by  first  mixing  the  salt  with  4  to  5 
parts  of  hot  water.    It  fuses  with  decomposition  at  -\-  268°  C. 

Benzoyl-vinyl-diacetoue-alkamine  was  proposed  by  Vinci  as  a  local 
anesthetic  in  1897;  it  is  an  alkaloid  related  to  Tropacocain  (q.  v.) 
Vinci  termed  it  eucain-B  (beta-eucain),  while  the  earlier  preparation, 
which  is  decidedly  of  less  value,  had  been  designated  eucain-A  (g.  v.). 
This  nomenclature,  as  shown  by  Marcinowski,  gave  rise  to  some  confu- 
sion and  error;  but,  since  eucain-A  is  now  off  the  market,  this  need  no 
longer  exist.  The  free  base,  the  proper  eucain-B,  is,  like  cocain  and 
eucain-i^,  almost  insoluble  in  water;  but  it  combines  with  acids  to  form 
soluble  salts,  of  which  that  with  hydrochloric  acid  has  been  most  em- 
ployed. It  is  for  this  reason  that  beta-eucain  hydrochlorid  has  been 
commonly  referred  to  as  eucain-B  or  beta-eucain.  The  preparation  has 
displaced  eucain-A,  and  is  employed  as  a  local  anesthetic  in  dentistry 
and  ophthalmic  practice,  and,  like  cocain,  is  mixed  with  ethyl  chlorid  for 
inducing  local  anesthesia  by  spraying  or  plugging. 

Schmitt  (Nouveaux  remedes,  1897,  353)  stated  that  eucain-B  is 
superior  to  eucain-A,  since  it  is  2  to  3  times  less  poisonous,  and  it  has 
been  pointed  out  that  it  is  less  toxic  than  eucain-A,  in  the  proportion  of 
one  to  four  (Francis  and  Fortescue-Brickdale's  "The  Chemical  Basis  of 
Pharmacology,"  1908,  307).  It  has  been  stated  that  it  is  somewhat 
painful  to  inject,  and  that  it  dilates  the  blood  vessels,  and  so  promotes 
bleeding — disadvantages  which  may  be  overcome  by  injecting  beta- 
eucain  in  normal  saline  at  body  temperature,  or  by  mixing  some  adrena- 
lin solution  with  the  preparation. 

As  mentioned  under  eucain-A,  it  was  ascertained  that  eucain-B  is  par- 
ticularly adapted  for  ophthalmic  operations  in  1897  (see  Darier:  La 
Clinique  ophthalmol,  1897,  210;  Dolganoff:  Wratsch,  1896,  No.  51; 
Mayrard:  Indian.  Med.  Gaz.,  1897,  44;  Silex:  Therap.  Monatsh., 
June,  1897;  and  Sweet:  Am.  Therap.,  1897,  No.  8).  In  1898  its  util- 
ity had  not  received  general  recognition,  although  a  number  of  physi- 
cians spoke  in  its  favor,  and  it  was  given  as  an  opinion  by  several  recog- 
nized medical  authorities  that  cocain  was  a  more  satisfactory  anesthetic. 
Eeclus  (Semaine  med.,  1898,  No.  18,  193),  supported  by  Legrand 
(Nouveaux  remedes,  1898,  No.  11,  251)  recognized  the  main  disad- 
vantages of  eucain-B,  as  compared  with  cocain,  in  the  fact  that  its  anes- 
thetic action  was  observed  to  be  a  little  feebler,  and  that  in  consequence 
of  its  vasodilatory  properties  it  produced  hemorrhages,  besides  causing 
pain  when  injected;  and  Wohlgemuth  (Deut.  med.  Ztg.,  1898,  No.  33, 
337)  pointed  out  that  the  view  that  eucain-B  was  less  toxic  than  cocain 
was  based  upon  a  delusion.     Consequently,  many  looked  upon  eucain-B 


A   LIST    OF    ANESTHETICS  755 

as  by  no  means  a  complete  substitute  for  eoeain,  and  only  regarded 
tropacocain  as  such.  In  the  next  year,  however,  we  find  Bardet,  Bolo- 
gnesi,  and  Touchard  {Nouveaux  remedes,  1899,  No.  3,  49)  employing 
eucain-B,  like  cocain,  mixed  with  ethyl  chlorid  for  inducing  local  anes- 
thesia by  spraying  or  plugging,  although  the  results  of  this  method 
were  hardly  so  favorable  as  those  obtained  with  cocain-ethyl  chlorid.  In 
this  year  Porter  (Brit.  Med.  J.,  1899,  No.  2010,  84)  recorded  a  case  in 
which  the  injection  of  eucain  into  the  prepuce,  preparatory  to  circum- 
cision, gave  rise  to  an  extensive  edema  of  the  penis  and,  ultimately,  sup- 
puration at  the  site  of  injection.  Experiences  of  this  kind  seemed  to  in- 
dicate that  cocain  and  eucain  were  by  no  means  identical  in  their  action, 
and  that  they  were  only  partially  equivalent. 

In  1900  Lohmann  recommended  eucain-B  as  a  substitute  for  cocain 
in  Schleich's  method  of  infiltration  (Therap.  Monatsh.,  1900,  No.  9,  478). 
In  the  opinion  of  Engelmann  (Miinch.  nied.  Woch.,  1900,  No.  44, 
1532),  however,  eucain-B  was  not  available  as  a  substitute  for  cocain  in 
Bier's  method  of  cocainizing  the  spinal  cord,  since  it  did  not  in  this  re- 
spect possess  any  advantage  over  cocain. 

In  1901  Gray  (Lancet,  1901,  No.  4045)  published  new  methods  of 
applying  eucain-B ;  he  employed  the  compound  in  combination  with  co- 
cain for  local  anesthesia  in  the  ear,  nose,  and  throat.  In  opposition  to 
the  view  of  Engelmann,  expressed  the  previous  year,  Fink  (Prager  med. 
Woch.,  1901,  April  11  and  18)  recommended  eucanization  of  the  spinal 
cord  by  Bier's  method  in  those  cases  in  which  cardiac,  pulmonary,  and 
renal  complications,  or  the  age  and  feebleness  of  the  patient,  precluded 
the  narcosis  by  chloroform.  It  was  at  this  time  that  beta-eucain  ace- 
tate (q.  V.)  began  to  be  used. 

More  recently  eucain-B  has  been  used  with  successful  results  in  the 
treatment  of  sciatica  by  Lange  (Munch,  med.  Woch.,  1904,  No.  52),  and 
by  Opitz  (Klin.-therap.  Woch.,  1907,  No.  14)  and  Gallatia  (Gynakol. 
Rundschau,  1907,  No.  21). 

H.  Braun,  in  his  text-book  on  local  anesthesia,  published  in  Leipzig 
in  1905,  pays  many  tributes  to  the  properties  of  eucain-B.  He  points  out 
that  he  and  Heinze  have  shown  that  it  is  entirely  equal  in  effect  to 
cocain  when  endermically  administered,  and  that  there  is  no  pain  or 
specific  irritation  from  the  injection  even  when  10  per  cent  solutions, 
made  with  the  aid  of  heat,  are  employed.  Even  0.005  per  cent  solutions 
effect  a  distinct  diminution  of  sensibility,  and  eucain  anesthesia  is 
slightly  less  persistent  than  cocain  anesthesia  under  like  conditions, 
although  a  1.5  per  cent  beta-eucain  solution  has  about  the  same  effect  as 
a  1  per  cent  cocain  solution  in  the  duration  of  the  anesthesia.  No  dam- 
age, we  are  told,  is  done  to  the  tissues  by  the  injection  of  an  osmotically 
indifferent  and  moderately  concentrated  beta-eucain  solution.  Braun 
also  states  that  the  local  anesthetic  properties  of  beta-eucain  solutions 


756  ANESTHESIA 

are,  in  general,  equal  to  those  of  a  cocain  solution  of  slightly  less  con- 
centration; its  diffusive  action  is  somewhat  less,  but  it  can  be  increased 
by  making  the  solution  stronger.  Dolbeau,  Schmidt,  Dumont,  and  Le- 
grand  found  that  the  fatal  dose  of  beta-eucain  was  3  to  3%  times 
greater  than  that  of  cocain;  Braun's  experiments  gave  similar  results 
for  equal  concentrations,  but  he  could  not  agree  with  Dolbeau  when  he 
stated  that,  on  intravenous  injection,  beta-eucain  was  as  poisonous  as 
cocain.  He  found  that  there  was  an  important  difference  in  favor  of 
beta-eucain  under  these  circumstances.  Braun  stated  that  the  literature 
contains  no  records  of  poisoning  by  beta-eucain,  except  in  the  cases  in 
which  it  was  employed  for  lumbar  anesthesia.  He  thought,  however, 
that  these  ill  effects  after  lumbar  injection  were  undoubtedly  chiefly  due 
to  the  actual  contact  effects  of  the  injected  fluid  on  the  central  nervous 
system,  and  that  they  were  not  due  at  all  to  absorption  phenomena. 

On  eucain-B  in  infiltration  analgesia,  see  Houghton :  J.  Roy.  Army 
Med.  Corps,  April,  1905;  Tinker:  J.  Am.  Med.  Assn.,  Feb.  11,  1905; 
and  Parker:     Chicago  Med.  Rec,  April  15,  1905. 

On  eucain-B  in  local  anesthesia,  see  Link:  Indiana  Med.  J.,  June, 
1905;  Harrison,  Ya.,  Hosp.  Bull,  Oct.  15,  1904;  Hildebrandt:  Berl 
Jclin.  Woch.,  May  1,  1905;  Marquis  and  Kraft:  J.  Am.  Med.  Assn., 
April  22,  1905;  Tuller:  Dental  Cosmos,  April,  1903;  Connell:  Ann. 
of  Surg.,  Dec,  1903  ;  Witherspoon :    Interstate  Med.  J.,  July,  1903. 

The  literature  relating  to  eucain-B  is  quite  extensive  and  cannot  be 
included  here  in  its  entirety.  Suffice  it  to  say  in  conclusion  that  it  is 
recorded  as  a  local  anesthetic  which  has  been  favorably  reported  upon 
in  more  than  one  hundred  journal  contributions;  that  it  is  said  to  pos- 
sess the  same  analgesic  power  as  cocain,  but  is  only  one-fourth  as  toxic; 
that  it  does  not  affect  the  heart  or  the  nervous  system,  not  causing  local 
irritation  or  general  intoxication;  that  it  is  devoid  of  the  stimulating 
powers  which  render  cocain,  particularly  when  used  in  the  nose  and 
throat,  so  seductive  a  drug;  and  that  its  solutions  are  permanent  and 
undergo  no  change  when  boiled. 

Dusterbehn  (Apoth.-Ztg.,  26,  22)  found  that,  when  eucain-B  is 
heated  at  +  100°  C.  with  10  times  as  much  sulphuric  acid,  benzoic  acid 
splits  off;  in  the  case  of  eucain-A,  however,  methyl  benzoate  is  formed. 
The  Deut.  Arzne.  states  the  contrary. 

On  reactions  for  differentiating  between  alpha  and  beta-eucain,  see 
Saporetti:  Boll.  chim.  farm.,  J/S,  479.  The  deportment  of  these  com- 
pounds with  various  reagents  is  given  and  discussed,  and  novocain, 
nirvanin,  alypin,  and  cocain  are  also  considered. 

Eucain  Acetate. — In  1901  eucain  acetate  (CigHoiISrOo.CaH.^Oo)  was 
recommended  in  the  place  of  beta-eucain  hydrochlorid,  being  said  to  sur- 
pass the  latter  as  regards  solubility. 

Cohn  {Med.  Woch.,  1901 ;  No.  36 ;  Therap.  Monatsh.,  1901,  No.  11, 


A   LIST    OF    ANESTHETICS  757 

595)  employed  eucain  acetate  in  the  form  of  a  2  per  cent  water  solution, 
and  produced,  with  the  application  of  as  little  as  4  or  5  drops,  complete 
anesthesia,  which  set  in  within  3  minutes  and  lasted  for  10  to  15  min- 
utes, so  as  to  be  available  for  the  extraction  of  foreign  bodies,  the  gal- 
vano-cauterization  of  corneal  ulcers  and  pterygia,  and  the  performance 
of  minor  operations  on  the  lacrymal  apparatus  and  the  conjunctiva. 
Eucain  acetate  therefore  appeared  to  be  well  adapted  for  minor  opera- 
tions on  the  eye — an  anesthetic  not  likely  to  fail  except  in  cases  where 
portions  of  the  anterior  half  of  the  bulbus  were  per  se  congested  with 
blood  and  irritated. 

Eucain  acetate  solutions  were  said  to  be  capable  of  boiling  without 
danger  of  decomposition.  This  salt  of  eucain  is,  however,  no  longer  on 
the  market. 

Eucain  Lactate. — Beta-eucain  lactate  (3,  6,  6-trimethyl-4-benzoxy- 
piperidin  lactate;  benzoyl vinyldiacetone-alkalamin  lactate)  has  the  fol- 
lowing composition: 

CH.O.CO.CcHb 


HaC 


■>c 

CHs 


CH, 


CH.CHs 
NH.CHo.CH(OH).COOH 


It  is  a  white  crystalline  powder,  fusing  at  about  -|-  152°  C.  and  pos- 
sessing the  following  solubility  at  the  ordinary  temperature : 

In  water 22  per  cent. 

In  alcohol 11    "      " 

In  chloroform 20    "      " 

In  glycerin 5    "      " 

The  water  solution  is  feebly  alkaline  to  litmus.  One  part  of  eucain 
lactate  is  said  to  be  soluble  in  5  parts  each  of  anilin  and  alcohol,  and 
it  may  be  dissolved  in  paraffin  oil  by  the  aid  of  chloroform.  It  is  said 
to  be  insoluble  in  olive  oil  and  paraffin  oil  alone,  and  not  to  be  soluble 
in  ethyl  ether  in  material  amounts.  Suspensions  in  lanolin  and  the 
heavy  mineral  oils  may  be  prepared  by  first  mixing  the  salt  in  4  or  5 
parts  of  hot  water. 

Beta-eucain  lactate  is  prepared  according  to  the  process  claimed  in 
U.  S.  Patent  657,880  of  Sept.  11,  1900.  It  is  said  to  have  all  the  prop- 
erties of  Beta-eucain  Hydrochlorid  (q.  v.),  but  to  possess  the  advan- 
tage of  being  over  six  times  as  soluble  in  water. 


758  ANESTHESIA 

Langgaard  {Therap.  Monatsh.,  1904,  No.  8,  416)  advocated  the  em- 
ployment of  eucaiii  lactate  for  local  anesthesia,  since  he  found  it  to  be 
non-irritant,  to  induce  neither  hyperemia  nor  local  anemia,  and  to  cause 
no  shrinkage.  He  stated  that  it  is  appropriately  applied  in  the  form  of 
the  following  solutions : 

In  ophthalmic  surgery 2        to    3  per  cent,  solutions. 

In  dental  surgery 2        to    3    "       "  " 

In  anesthesia  by  infiltration 0. 12 "       "         " 

In  regionary  anesthesia 2        to    5   "       "         " 

Surgery  of  nose,  throat  and  ear 10        to  15   "       "         " 

According  to  Langgaard,  solutions  of  a  concentration  of  less  than  1  per 
cent  should  have  added  thereto  0.8  per  cent  of  sodium  chlorid,  0.6 
per  cent  of  which  should  be  added  to  1  to  2  per  cent  solutions  of  eucain 
lactate.  Katz  (ibid.,  1904,  No.  8,  419)  was  the  first  to  treat  diseases 
of  the  throat,  nose,  and  ear  with  the  aid  of  this  preparation,  whereby 
he  obtained  very  satisfactory  results.  Braun,  in  his  text-book  on  local 
anesthesia  referred  to  above,  stated  that  eucain  lactate  has  the  same 
anesthetic  effect  as  the  hydrochlorid,  and  is  equally  free  from  irritative 
properties.  He  recommended  that  it  be  used  instead  of  beta-eucain 
when  a  readily  soluble  salt  of  eucain  is  desired. 

On  the  use  of  eucain  lactate  in  eye,  nose,  ear,  and  throat  work, 
see  the  following : 

Ellis:  Cal.  State  J.  of  Med.,  May,  1905;  Harris  and  Wilson: 
Laryngoscope,  June,  1905;  Meyer:     Therap.  Monatsh.,  May,  1"905. 

On  its  iise  in  ano-rectal  surgery,  see  Pennington:  J.  Am.  Med. 
Assn.,  April  8,  1905;  and  Am.  Med.,  July  29,  1905. 

Eucain-snuifpowder. — Lactose  with  2  to  3  per  cent  of  eucain  hydro- 
chlorid, also  with  an  addition  of  0.01  per  cent  of  adrenalin. 

Eucalyptus  Extract. — This  has  been  used  as  a  local  anesthetic  in 
dental  operations. 

Eucapren. — A  local  anesthetic  solution  of  suprarenalin  (1  in  5,000) 
containing  1  per  cent  of  beta-eucain  lactate. 

Eucarenalin. — An  anesthetic  consisting  of  a  1  per  cent  solution  of 
beta-eucain  lactate  in  1  to  2,000  of  suprarenalin.  This  preparation  was 
made  for  the  English  market,  but  the  name  is  now  discontinued.  See 
Eucapren. 

Eudont. — Two  separate  liquids :  One  a  solution  of  oil  of  cloves,  cam- 
phor, alcohol,  and  chloroform;  and  the  other  a  mixture  of  tincture  of 
iodin,  glycerin,  and  tincture  of  opium.  Eudont  is  employed  in  den- 
tistry. 

Eudrenin. — This  is  a  solution  of  eucain  hydrochlorid,  intended  for 
dental  local  anesthesia,  the  local  anesthetic  effect  of  Avhich  is  said  to  be 
augmented  and  prolonged  by  the  addition  of  adrenalin  chlorid,  this  lat- 


A   LIST    OF    ANESTHETICS  759 

ter  compound  having  the  power  of  contracting  the  capillaries  and  thus 
preventing  the  distribution  of  the  eucain  hydrochlorid  throughout  the 
system. 

Eudrenin  is  offered  to  the  trade  in  1  c.  c.  ampules  for  hypodermic 
injection,  and  possesses  the  following  composition: 

Beta-eucain  hydrochlorid 0 .  25  per  cent. 

Adrenalin  chlorid 1:10,000. 

Both  compounds  are  dissolved  in  physiologic  salt  solution,  1  c.  c. 
Each  ampule  therefore  contains  beta-eucain  hydrochlorid,  0.0025  gm. ; 
adrenalin  chlorid,  0.0001  gm. ;  and  physiologic  salt  solution,  q.  s.  See 
Beta-eucain  Hydrochlorid. 

Eugallol. — Ehrmann  {Therap.  Monatsh.,  1910,  No.  5,  230)  used 
Eugallol  (pyrogallol  monacetate)  in  an  aqueous  or  oily  dilution  in  the 
treatment  of  chronic  proliferating  catarrh,  etc.,  and  called  the  remedy 
a  "caustic  anesthetic"  or  a  "caustic  mucous  membrane  anesthetic,"  in 
opposition  to  the  anesthesia  of  purely  peripheral  neurotic  origin  pro- 
duced by  cocain,  and  to  the  local  anesthesia  produced  by  cold. 

Eugenol  (Eugenic  acid;  carpophyllic  acid;  para-oxy-meta-methoxy- 
allyl-benzene). — Used  in  dentistry  as  a  local  anesthetic.  An  old-fash- 
ioned remedy  for  toothache  consisted  in  filling  the  cavity  with  a  clove, 
which  owes  its  anesthetic  properties  to  eugenol.  Like  all  the  phenols, 
eugenol  acts  on  nerve  endings.  Eugenol  was  recommended  by  Eed- 
man  (Hollander-Schneidermlihl's  "Handbuch  der  zahnarztl.  Heilmit- 
tellehre,"  1890,  149)  as  an  anesthetic  suitable  for  sensitive  dentine.  It 
was  reported  upon  by  Wittel,  Scheuer,  and  Eichter  (J.  f.  Zalinlieillcunde, 
1902,  No.  12,  115),  and  Hertwig  (ibid.)  praised  eugenol  as  an  excellent 
antiseptic  and  anesthetic  for  sensitive  dentine  and  for  the  pulp. 

On  Eugenol  as  an  anesthetic,  see  Cohn:     Pliarm.  Centralh.,  40,  33. 

Eugenol  Acetamid. — This  compound, 

CJl3.C3H5.0Cli3.0CH3.C0NH2, 
is  used  in  the  form  of  a  fine  powder  in  the  place  of  cocain  as  a  local 
anesthetic    on    mucous    surfaces.      It    forms    glossy    scales,    fusing    at 
-f  110°  C. 

On  this  preparation,  see  Cohn :     Pliarm.  CentraTJi.,  J^O,  33. 

Eugenol-alcohol. — On  this  preparation  as  a  local  anesthetic,  see 
Cohn :    Pharm.  Cenlralli.,  J^O,  33. 

Eugenol  Esters  of  the  Aminobenzoic  Acids. — Eiedel,  in  German 
Patent  203,093,  of  Nov.  7,  1907,  claims  the  substitution  for  the  hereto- 
fore employed  anesthetics,  carbolic  acid,  eugenol,  creosote,  and  other 
phenol  derivatives,  of  the  eugenol  esters  of  the  aminobenzoic  acids,  in 
the  application  of  arsenic  trioxid  as  a  tooth  nerve  devitalizer. 

Euphorin. — See  Phenyl-uretliane. 


760  ANESTHESIA 

Eupnema  (Eupneuma). — This  remedy  for  asthma  contains  1  part 
of  anesthesin  and  2  parts  of  subcutin  in  100. 

Euroform  Paste. — This  dental  anodyne  and  wound  packing  consists 
of  orthoform  1  dram,  europhen  II/2  drams,  petronol  21/2  drams,  and 
white  petrolatum  21/2  drams. 

Euscopol. — ^A  ^'chemically  pure,  inactive  Scopolamin  Hydrohromid 
(q.  v.),  free  from  foreign  bases."  It  forms  colorless  crystals,  melting  at 
+  180-181°  C,  and  is  soluble  in  water  and  alcohol.  See  Adam:  Med. 
KliniJc,  1911,  No.  52,  2026. 

Eusemin  or  Eusemine. — A  sterile  solution  in  hermetically  sealed 
vials  of:  Cocain  hydroehlorid,  0.0075  gm.  (0.116  grain) ;  and  adrenalin 
hydrochlorid,  0.00005  gm.  (8/1,000  grain),  dissolved  in  physiologic  salt 
solution,  1  c.  c.  Littaur  (Deut.  med.  Woch.,  35,  1277)  states  that 
eusemin  is  a  mixture  of  cocain  with  adrenalin  in  physiological  salt  solu- 
tion. He  considered  it  of  value  as  a  local  anesthetic.  Gehes  Codex 
(Nov.,  1910,  119)  states  that  eusemin  is  a  solution  of  0.75  per  cent 
cocain  hydrochlorid  and  5  per  cent  of  a  1:1,000  adrenalin  solution  in 
physiological  salt  solution.  Eiedel's  "Mentor"  (1911,  153)  states  that 
each  c.  c.  contains  0.0075  gm.  cocain  hydrochlorid  and  0.00005  gm. 
adrenalin  hydrochlorid  in  physiological  salt  solution. 

ISTeuhann  {Med.  Klinih,  8,  780)  stated  that  the  toxicity  of  eusemin 
was  reduced  to  a  minimum  on  account  of  its  small  content  of  cocain  and 
adrenalin.    He  reported  that  it  is  sterilized  in  an  autoclave. 

Falkenstein's  Zahnpasta. — A  paste  said  to  contain  an  "antiseptic 
anesthetic." 

Eilodentol  BertagnoUi. — A  red-colored  alcoholic  solution  of  oils  of 
cinnamon  and  peppermint,  intended  for  the  treatment  of  odontalgia. 

Formal. — See  MethyJal. 

Formaldehyd-kelene. — Kelene  (q.  v.)  containing  formaldehyd  for 
use  in  treating  hay  fever,  catarrh,  etc. 

Formanilid. — This  compound,  phenyl  foramid  (CgHg.lSrH.CHO),  is 
a  reaction  product  of  anilin  and  formic  acid.  It  occurs  in  colorless  to 
yellowish  crystals,  which  are  soluble  in  water  and  alcohol,  and  which 
melt  at  +  46°  C.  In  a  paper  by  Kossa,  Tauszk,  Preisach,  and  Meisels 
{Magyar  Orvosi  Arch.,  through  Therap.  Blatter,  1893,  143),  for- 
manilid is  described  as  a  very  powerful  antipyretic,  also  acting  as  an 
analgesic,  producing  local  anesthesia,  even  when  employed  in  smaller 
quantity  than  cocain.  It  is  said  to  be  used  externally  in  20  per  cent 
solution  to  produce  local  anesthesia  in  one  hour.  Formanilid  is  also 
said  to  be  hemostatic. 

Formyl  Tribromid. — See  Bromoform. 

Fresenius  Anaesthesin-bormelin. — See  Ancestliesin-bormelin. 

Frohmann's  Solution. — A  dental  local  anesthetic  composed  of  cocain 
hydrochlorid,  0.2  part;  morphin  hydrochlorid,  0.25  part;  sodium  chlorid 


A   LIST   OF    ANESTHETICS  761 

(sterilized),  0.2  part;  antipyrin,  %  guaiacol,  2  drops;  and  distilled  wa- 
ter, 100  parts. 

Gajacyl. — See  Guaiacyl. 

Gasoline. — Used  as  a  local  anesthetic  in  1879.    See  Pentdne. 

Gasu-basu. — See  Nervocidin. 

Glacial. — A  mixture  of  methyl  and  ethyl  chlorids,  intended  for  use 
as  an  anesthetic. 

Gleditschin.— See  Stenocarpin. 

Goldschmidt's  Anaesthetics. — According  to  Goldschmidt  {Chem.- 
Ztg.,  26,  743),  p-phenetidin  and  its  homologues  give  with  o-formic  acid 
ester,  according  to  the  reaction  of  Claisen,  anesthetic  compounds  of  the 
type  of  methenyldi-p-phenetidin.  Goldschmidt  (see  Pharm.  Ztg.,  J^6, 
323)  stated  that  o-anisidin-ethyl-formate  and  o-phenetidinethylformate 
are  anesthetics. 

Gray's  Ansestheticum. — Cocain  hydrochlorid,  1;  anilin,  5;  diluted 
alcohol,  5.    For  use  in  ear  affections. 

Grehant's  Anesthetic. — A  4  per  cent  solution  of  morphin  is  given, 
1/4  c.  c.  per  kilogram  of  animal,  followed  in  half  hour  by  10  c.  c.  per 
kilogram  of  a  mixture  of  chloroform  50  c.  c.  and  alcohol  and  water  each 
500  c.  c.    See  McNider :    Proc.  Soc.  Exper.  Biol  and  Med.,  1913,  10,  95. 

Guaiacol. — This  compound  has  been  used  as  a  local  anesthetic;  it  is 
said  to  be  innocuous,  but  irritating.  On  the  production  of  complete 
anesthesia  by  the  cataphoresis  of  a  mixture  of  guaiacol  and  cocain,  see 
Morton:  Dental  Cosmos,  Jan.,  1896;  Berten:  Berl.  Jclin.  Woch.,  1896, 
No.  35,  769 ;  Marcus :  Deut.  med.  Woch.,  1897,  No.  10.  On  the  anes- 
thetic action  of  Guaiacol,  see  Cohn:     Pharm.  Centralh.,  J/.0,  33. 

Holland  {De7ital  Brief,  1901,  8;  Odontolog.  Blatter,  1902,  No.  13, 
254)  found  guaiacol  to  be  a  valuable  means  for  the  removal  of  pains 
in  pulpitis,  and  also  a  useful  addition  to  arsenic  and  cocain  caustic 
paste.  Hecht  {Therap.  der  Gegenwart,  1909,  354)  published  a  report 
on  the  use  of  guaiacol  as  an  anesthetic  and  antiphlogistic;  this  is 
worthy  of  careful  perusal  by  every  physician,  for,  although  the  external 
use  of  guaiacol  has  not  met  with  great  favor,  this  may  be  largely  at- 
tributed to  a  certain  prejudice  founded  on  the  bad  effects  displayed  by 
excessive  amounts. 

Guaiacol  dissolved  in  olive  oil  has  been  employed  as  a  local  anes- 
thetic, although  this  solution  has  not  met  with  general  favor.  It  was 
introduced  by  Lucas-Championniere.  According  to  Heineck  ("General 
and  Local  Anaesthesia,"  1909,  79),  it  does  not  produce  anesthesia  as 
rapidly  as  cocain;  it  can  cause  sphacelus;  it  does  not  always  produce 
anesthesia;  and  there  is  considerable  irritation  at  the  periphery  of  the 
area  of  injection. 

On  the  employment  of  guaiacol  as  a  local  anesthetic,  see  thei  follow- 
ing contributions: 


762  ANESTHESIA 

Benoit:  "Du  gaiacol  efc  de  la  cocaine  consideres  comme  anesthe- 
siques  locaux,"  These  de  Paris,  1896. 

Championniere :  "Le  gaiacol  comme  anesthesique  local  et  discus- 
sion," Bull,  de  VAcad.  de  Med.,  July  23,  1895;  La  France  med.,  1895, 
No.  31";  "Emploi  du  gaiacol  pour  I'anesthesie  locale  en  reraplacement  de 
la  cocaine,"  Bull,  de  VAcad.  Med.,  1895,  No.  30;  "Emploi  du  gaiacol  pour 
Tanesthesie  locale  en  remplacement  de  la  cocaine,"  Lyon  med.,  1895,  ISTo. 
33 ;  "Anesthesie  locale  par  le  gaiacol,"  J.  de  Med.  et  de  Chir.  Pratiques, 
1895,  No.  17. 

Coutant:  "Contribution  a  I'etude  des  anesthesiques  locaux  et  en 
particulier  du  gaiacol  en  injections  intracutanees,"  These  de  Bordeaux, 
1896. 

Malot :  "Des  injections  sous-cutanees  de  gaiacol  chloroforme  comme 
analgesique  local,"  These  de  Paris,  1897. 

O'Followell :  "L'Anesthesie  locale  par  le  gaiacol,  le  carbonate  de 
gaiacol  et  le  gaiacyl,"  These  de  Paris,  1897. 

Eeclus:  "Sur  la  valeur  comparee  du  gaiacol  et  de  la  cocaine  dans 
I'anesthesie  locale,"  Bull,  de  VAcad.  de  Med.,  1896,  No.  20. 

Guaiacol  Benzyl  Ester. — See  Benzcain. 

Guajacid,  or  Guaiacyl. — Calcium  guaiacol  monosulphonate, 
[(C,H,0,S03),Ca] 
is  a  grayish-white  powder,  freely  soluble  in  water  and  alcohol,  but  in- 
soluble in  fatty  oils.  It  acts  like  guaiacol,  as  an  innocuous  local  anes- 
thetic [Andre:  J.  Pharm.  Chim.,  1898,  (6),  7,  i,  324;  and  Followell: 
Presse  medicale,  1898,  No.  25].  Capitain  (Beige  medicale,  1898,  691) 
praised  guaiacyl  on  account  of  its  antiseptic  and  anesthetic  properties, 
as  well  as  on  account  of  its  harmlessness.  It  is  said  to  have  been  used  in 
minor  surgery,  dentistry,  etc. 

Guaiasanol  (Gujasanol) . — Diethylglycocoll-guaiacol  hydrochlorid, 
CeH,(0CH3).[CH_.N(C2H3),.C00].HCl  =  Ci3H,9N03HCl,  is  the  hy- 
drochlorid of  diethylglycocoll-guaiacol.  It  is  prepared  by  the  action  of 
chloracetylchlorid  on  guaiacol  and  decomposition  of  the  product  with 
diethylamin.  It  forms  small,  colorless,  prismatic  crystals,  melting  at 
-f  183°  to  184°  C.  (361.4°  to  363.2°  F.),  having  a  slight  odor  of 
guaiacol  and  a  bitter  saline  taste.  It  is  soluble  in  its  own  weight  of 
water  and  in  25  parts  of  alcohol,  but  is  insoluble  in  ether.  The  solu- 
tion in  water  should  be  clear,  colorless,  and  give  a  white  precipitate 
with  silver  nitrate.  The  oily  base  separates  on  the  addition  of  an  alkaline 
hydroxid.  When  incinerated  on  platinum  it  leaves  no  residue.  It  is  in- 
compatible with  alkalies  and  their  carbonates. 

Actions  and  Uses.— It  is  antiseptic  and  anesthetic.  It  is  readily  ab- 
sorbed and  splits  off  guaiacol  in  the  organism  with  facility.  Its  anti- 
septic power  is  said  to  be  about  equivalent  to  that  of  boric  acid.  Guai- 
asanol has  been  recommended  for  the  treatment  of  tuberculosis,  both  in- 


A   LIST    OF    ANESTHETICS  763 

ternally  and  subcutaneously.     It  is  also  said  to  be  useful  as  a  deodorant 
and  to  have  given  good  results  in  putrid  cystitis. 

Guaiasanol  has  been  tested  pharmacologically  by  Heinz,  bacteriologi- 
cally  by  Biichner,  and  clinically  by  P]inhorn  {Munch,  med.  Woch.,  1900, 
No.  1, 11).  Schafer  (ibid.,  1903,  No.  31,  13G3)  employed  it  in  the  treat- 
ment of  tuberculosis  of  the  larynx  as  well  as  of  the  bones;  and  Rahn 
{ibid.^  1905,  783  and  1806)  used  the  preparation  successfully  in  the 
treatment  of  oxyuris  vermicularis  and  for  a  mouth  deodorant.  It  is 
said  that,  when  a  1  per  cent  solution  is  used  for  superficial  wounds  of 
the  eye,  there  is  quite  a  perceptible  anesthetic  effect. 

Dosage. — One  to  three  gm.  (15  to  45  grains)  in  wafers;  subcutane- 
OTisly,  3  to  4  gm.  (45  to  60  grains)  in  20  per  cent  aqueous  solution;  lo- 
cally it  may  be  used  in  from  0.1  to  2  per  cent  solutions. 

Gujasanol. — See  Guaiasanol. 

Gummitropakokain. — Sterile  ampules  containing  1.2  c.  c.  gum  solu- 
tion and  0.05  gm.  Tropacocain  Hydroclilorid  {q.  v.).  On  the  employ- 
ment of  this  combination  in  lumbar  anesthesia,  see  Hertel:  Munch, 
med.  Woch.,  1910,  No.  16,  844. 

Hedonal  (Methylpropylcarbinol  urethane;  pentan-2-ol-urethrane) . — 
Hedonal  is  pentan-2-ol-urethane,  CH3.CH„.CH,.CH(CH3)O.CO.NH2  = 
CgH^gOgN.  It  is  a  derivative  of  urethane,  differing  from  ethyl  car- 
bamate, U.  S.  P.,  in  that  the  ethyl  radicle  has  been  replaced  by  the 
radicle  of  methyl-propylearbinol  (pentan-2-ol), 

CH,.CH,.CH2.CH0H.CH3. 
It  is  prepared  by  heating  the  secondary  methylpropylcarbinol  or  pentan- 
2-ol.  CHg.CHo.CHo.CHOH.CH,  with  urea  nitrate  under  pressure 
(U.  S.  Patent  No.  659,202),  also  by  other  methods  (German  Patents 
Nos.  120,863,  120,864,  120,865.  It  is  a  white,  crystalline  powder,  hav- 
ing a  faint  aromatic  odor  and  taste,  melting  at  -(-  74°  C.  (165.2°  F.), 
and  boiling  at  -)-  215°  C.  (419°  F.).  It  dissolves  in  120  parts  of  water 
at  37°  C.  (98.6°  F.),  but  is  more  soluble  at  higher  temperatures,  and  is 
readily  soluble  in  alcohol,  ether,  chloroform,  and  other  organic  solvents. 
It  is  readily  volatilized  with  the  vapors  of  water  or  alcohol,  and  when 
boiled  with  alkalies  it  is  split  up  into  its  constituents,  methyl-propylear- 
binol, ammonia,  and  carbon  dioxid. 

On  boiling  with  dilute  sodium  hydroxid,  ammonia  is  evolved,  and 
may  be  recognized  by  the  odor  and  the  usual  reagents;  if  then  an  aque- 
ous solution  of  iodin  in  potassium  iodid  is  added,  and  the  mixture  is 
allowed  to  cool,  the  odor  of  iodoform,  derived  from  the  alcohol,  is  dis- 
tinctly manifested.  It  is  incompatible  with  alkalies,  their  carbonates, 
and  bicarbonates. 

Actions  and  Uses. — Hedonal  appears  to  have  a  greater  hypnotic  ef- 
fect than  ethyl  carbamate.  It  is  said  to  be  followed  by  no  bad  after- 
effects, and  to  be  oxidized  in  the  body  to  urea  and  carbon  dioxid.     It  is 


764  ANESTHESIA 

employed  in  insomnia  due  to  mental  overwork,  or  nervous  excitement  oc- 
curring in  the  course  of  neurasthenia  or  hysteria.  It  is  claimed  to  be  a 
particularly  useful  preliminary  to  anesthesia,  a  hypnotic  dose  being 
given,  and  anesthesia  is  effected  with  chloroform  after  the  patient  has 
been  asleep  for  an  hour;  and  recently  it  has  been  found  to  be  applicable 
by  itself  as  an  anesthetic  for  operations,  especially  if  it  is  applied  intra- 
venously.    See  Z.  fur  Chir.,  108,  5-6. 

When  hedonal  is  employed  as  a  preliminary  to  general  anesthesia  with 
chloroform,  it  must  be  given  at  least  one  hour  before  the  anesthetic,  for 
its  absorption  is  slow.  There  are  said  to  be  objections  other  than  this 
to  its  use  in  this  manner.  On  hedonal  as  an  anesthetic  when  applied 
intravenously,  see  Sichkovski :  Russkiy  Yrach,  9,  1447 ;  Fedoroff :  Zen- 
tralbl.  f.  Chir.,  1910,  No.  9;  Russisches:  J.  f.  Gehtirtshilfe  u.  Gynakol., 
1910,  Nos.  5  and  G;  Sidorenko:  ZentralU.  f.  Chir.,  1910,  No.  37.  On 
chloroform-hedonal  anesthesia,  see  especially  Krawkoff:  Russkiy 
Wratsch,  1910;  Therap.  Monaish.,  1910,  444.  On  intravenous  hedonal 
anesthesia,  see  Sidorenko:  Zentr.  Chirurg.,  1910,  No.  37,  1219;  Jere- 
mitsch:  Deut.  Z.  Chir.,  1911,  108,  Nos.  5-6;  Krzizewsky:  Russkiy 
Wratsch,  1911,  No.  13;  Albinsky:  Ibid.;  Fedoroff:  Therap.  Gegen- 
wart,  1911,  268;  Allg.  med.  Zentralztg.,  1911,  305;  Zentr.  Chir.,  1910, 
No.  19,  675;  Lytschkowski :  Petershurger  med.  Woch.,  1911,  209.  The 
last  five  authors  confirm  the  advantages  of  this  method  of  anesthesia 
on  the  whole.    For  a  late  report,  see  Page :    Lancet,  182,  1258. 

Dosage. — One  to  two  gm.  (15  to  30  grains),  administered  dry,  fol- 
lowed by  a  swallow  of  water,  or  in  wafers  or  capsules. 

Hedonal  tablets,  8  grains.  Each  tablet  contains  hedonal  0.52  gm. 
(8  grains). 

Helleborein. — A  glucose  from  Helleborus  niger  (Winter  Eose; 
Black  Bears  Foot),  used  as  a  local  anesthetic  in  ophthalmic  surgery; 
on  the  cornea  3  to  4  drops  of  a  solution  containing  in  1  drop  0.0005  gm. 
is  said  to  give  complete  anesthesia,  without  irritation,  lasting  30  minutes. 
It  is  a  yelloAvish  powder,  possessing  the  composition  Cg^HsaOig,  and  is 
soluble  in  water  and  alcohol. 

Heufibrol-creme  Stauflfer. — This  contains  Anesthesin  (q.  v.)  and 
homorenon   (ethylamino-acetobrenzcatechin  hydrochlorid) . 

Heufieber-renitol. — Extract  of  suprarenal  gland  with  a  local  anes- 
thetic. 

Hewitt's  C.  E.  Mixture. — Chloroform,  2  parts  by  volume ;  and  ether, 
3  parts  by  volume.  Mix.  See  Hewitt :  "Anaesthetics  and  Their  Admin- 
istration," 3rd  ed.,  462. 

Hexahydrophenanthrene. — According  to  Brissemoret  (Compt.  rend. 
8oc.  Biol.,  69,  497),  this  compound  has  a  narcotizing  power  on  such 
warm-blooded  animals  as  the  rabbit. 

Hexamekol. — This  compound  of  guaiacol  with  hexamethylene-tetra- 


A   LIST    OF    ANESTHETICS  765 

min  is  said  by  Eabow  {Chem.-Ztg.,  1912,  No.  21,  190)  to  be  an  anes- 
thetic. On  its  employment  in  practice,  see  Liidin :  Munch,  med.  Woch., 
1911,  48;  Chem.-Ztg.,  Repert.,  1911,  554. 

Hexane. — This  hydrocarbon  is  said  to  be  actively  intoxicant,  produc- 
ing a  long  stage  of  excitement,  followed  by  deep  anesthesia  (Francis 
and  Fortescue-Brickdale's  "The  Chemical  Basis  of  Pharmacology," 
1908,  45).  It  has  never  been  employed  as  an  anesthetic,  however.  See 
Octane. 

Holocain  and  Adrenalin  Ointment. — An  ointment  said  to  consist  of 
holocain,  1  per  cent;  adrenalin  chlorid,  4  per  cent;  hydrous  wool  fat,  10 
per  cent;  and  white  petrolatum,  85  per  cent.  It  is  put  up  in  collapsible 
tubes  for  application  to  the  eye. 

Holocain  Hydrochlorid  (Holocainse  Hydrochloridum ;  Ethenyl- 
para-diethoxy-diphenyl-amidin  Hydrochlorid) . — Holocain  hydrochlorid 
is  phenetidy-acetphenetidin  hydrochlorid,  CH3C( :  IST.CBH^.OCgHg) 
(.NH.C6H,.0C2H5) .HCl  =  CigH^.N.OoHCl.  Phenetidyl-acetphenetidin 
hydrochlorid  is  the  hydrochlorid  of  a  basic  condensation  product  of 
para-phenetidin  (para-ethoxy-amino-benzene)  and  acetparaphenetidin 
(phenacetin).  It  is  prepared  by  the  interaction  of  molecular  propor- 
tions of  para-phenetidin  sulphate  and  acetphenetidin  (phenacetin)  in 
the  presence  of  phosphorous  oxychlorid,  decomposing  the  resulting  holo- 
cain sulphate  with  sodium  hydroxid,  crystallizing  the  base  from  alcohol, 
neutralizing  it  with  hydrochloric  acid,  and  crystallizing.  It  was  first 
prepared  by  Tauber  (see  Centr.  f.  praht.  Augenlieilhunde,  1897,  30). 

It  forms  small,  colorless  crystals,  neutral  or  faintly  alkaline,  melt- 
ing at  -{-  189°  C.  (372.2°  F.),  odorless,  faintly  bitter,  and  producing 
transient  numbness  on  the  tongue.  It  is  soluble  in  50  parts  of  water  and 
freely  soluble  in  alcohol.  On  boiling  in  ordinary  glass  vessels,  the  water 
solution  becomes  turbid,  owing  to  a  separation  of  a  small  quantity  of 
the  free  base  by  the  alkali  derived  from  the  glass.  It  should  form  a 
clear,  colorless  solution  in  water,  neutral  or  faintly  alkaline,  yielding  a 
white  precipitate  on  addition  of  silver  nitrate  or  of  ammonia.  The  base 
obtained  by  precipitation  with  ammonia  and  crystallized  from  alcohol 
forms  colorless  needles,  which  melt  at  -|- 121°  C.  (249.8°  F.).  Incin- 
erated on  platinum,  it  leaves  no  weighable  residue.  It  is  incompatible 
with  alkalies  and  their  carbonates  and  the  usual  alkaloidal  reagents. 
Glass  vessels  should  be  avoided  in  preparing  the  solution,  porcelain  being 
used  instead.     Only  distilled  water  should  be  employed. 

Actions  and  Uses. — It  is  a  local  anesthetic  like  cocain,  but  having  the 
advantage  of  a  quicker  effect  and  an  antiseptic  action.  Five  minims  of 
a  1  per  cent  solution,  when  instilled  into  the  eye,  are  usually  sufficient  to 
cause  anesthesia  in  from  1  to  10  minutes.  It  is  said  not  to  cause  the 
scaliness  of  the, cornea  which  sometimes  results  after  the  use  of  cocain. 
It  should  never  be  given  internally  or  be  employed  hypodermically,  for 


766  ANESTHESIA 

it  is  said  to  be  toxic  when  so  used.  In  toxic  doses  it  produces  general 
convulsions. 

Dosage. — It  is  applied  in  a  1  per  cent  water  solution  prepared  in 
porcelain  vessels.  The  action  and  mode  of  application  of  holocain 
hydrochlorid, have  been  discussed  in  an  extensive  series  of  papers;  these 
follow  in  part. 

Kuthe :     Centr.  f.  prakt.  Augenheilk.,  Jan.,  1897,  55. 

Jaeuber:     Centr.  f.  prakt.  Augenheilk.,  Jan.,  1897,  53. 

Gutmann:    Deut.  med.  Woch.,  1897,  No.  11,  165. 

Deneffe:    Sem.  med.,  1897,  No.  15,  114. 

Berger:    Ihid.,  1897,  No.  31,  25. 

Lowenstamm:     Therap.  Monat.,  1897,  No.  5,  268. 

Winselmann:    Klin.  Monat.  f.  Augenheilk.,  May,  1897,  150. 

Hirschfeld:    Monat.  f.  Augenheilk. ,Ms.j,  19,21,  Ib'l. 

Natanson :    St.  Petersburg,  med.  Woch.,  1897,  No.  32,  304. 

Coosemanns:    Presse  med.,  1897,  No.  74,  83. 

Coosemanns:  Rev.  held,  de  Laryng.,  d'Otol.,  et  de  Rhin.,  Dec.  11, 
1897. 

Chevalier:  Bull,  de  therap.,  Oct.  23,  1897;  Nouveau  remedes,  1897, 
No.  20,  609. 

Lagrange  and  Crosse:    Bull,  med.,  1897,  No.  104,  1209. 

Lagrange  and  Crosse :    Bull,  med.,  Feb.  8,  1898. 

Gires :    These  de  Paris,  1897. 

Heinz:    Centr.  f.  prakt.  Augenheilk.,  March,  1897. 

Heinz  and  Schlosser:  Klin.  Monats.  f.  Augenheilk.,  April,  1897, 
114. 

Carter:    Lancet,  May,  1897,  1466. 

Derby :  Boston  Med.  and  Surg.  J.,  June  3,  1897 ;  and  Boston  Med. 
and  Surg.  J.,  Jan.,  1890. 

Wood:    Ann.  of  Ophthalmology,  Oct.,  1897. 

Holtz:    J.  Am.  Med.  Assn.,  Nov.  13,  1897. 

Masselon:    Arch.  d'Ophthalm.,  Oct.,  1897. 

Wurdemann:     Clinique  ophthalm.,  1898,  No.  5. 

Eandolphe-Westcott-Hotz :  Woch.  f.  Therap.  u.  Hygiene  des  Auges, 
1898,  No.  47. 

De  Landsheere:     Clinique  ophthalm.,  1898,  No.  16,  191. 

Snegirew:    Med.  Oboshrenie,  SO,  No.  4. 

Frassi:     Clinica  Moderna,  1898,  29. 

Wurdemann  and  Black :  Ophthal.  Rec,  Oct.,  1897,  and  Jan.,  1898. 

Hinshelwood:  Brit.  Med.  J.,  Sept.  3,  1898;  Glasgow  Med.  J.,  June, 
1904. 

Cheatham:     Am.  Pract.  and  News,  Aug.  15,  1898. 

Ellett:    Phil.  Med.  J.,  Nov.  26,  1898. 

Randolph:     J.  Am.  Med.  Assn.,  Sept.,  1898. 


A   LIST    OF    ANESTHETICS  767 

Trousseau:    La  Presse  med.,  Apr.,  1898,  No.  37. 

Hinshelwood:    Klin.-therap.  Woch.,  Sept.,  1898,  No.  39. 

Serin i :     Archives  d'OphAlial.,  Jan.,  1899. 

Knapp:    Archives  of  OphUial.,  May,  1899. 

Guttmann :    N.  Y.  med.  Monats.,  Nov.  3,  1899. 

Norris:    Ophthal.  Rec,  June,  1899. 

Schultz :    Archiv  f.  Augenheilh.,  1899,  J^O,  No.  2,  125. 

Jackson:     Col.  Med.  J.,  Dec.,  1899. 

Pyle:    West.  Med.  Rev.,  Jan.  15,  1900. 

Hale :    Chicago  Med.  Rec,  Feb.,  1900. 

Deane:    Pac.  Med.  J.,  June,  1900. 

Ellenbogen :    Rev.  therap.  med.-chir.,  Dec.  1,  1900. 

Holber  Mygind:  "Krankheiten  cler  oberen  Luftwege"  (Verlag  Os- 
car Coblentz,  Berlin),  1901. 

Brandt:    Zahndrztlich  Rundschau,  1901,  Nos.  468  and  469. 

Heineck:     The  Bacillus,  Jan.,  1901. 

Zirn:    Zentralh.  f.  praht.  Augenheilh.,  May,  1901. 

Coulter:    Ann.  of  Otol.,  Rhinol.  and  Laryng.,  Feb.,  1901. 

De  Schweinitz :     Therap.  Gaz.,  June  15,  1901. 

Calhoun:     Ophthal.  Rec,  Jan.,  1902. 

Knipp:    J.  Am.  Med.  Assn.,  Aug.  9,  1902. 

Briggs:     Occidental  Med.  Times,  Aug.,  1902. 

Oliver:     A?i/i.  of  Ophthal,  Oct.,  1903. 

Bock:  "Das  erste  Jahrzebnt  der  Abteilung  fiir  Augenkrauke  in 
Laibach,"  Wien,  1902;  Allgemeine  Wiener  medicinische  Zeitung,  1908, 
No.  36. 

Wainwright:     The  Am.  Therap.,  1904,  No.  1. 

Church:     Ophthalmology,  July,  1905. 

Hydramyl  (Amyl  Hydrid;  Pentylene). — Obtained  as  a  fraction  in 
the  distillation  of  petroleum  and  proposed  as  an  anesthetic.  See  Amyl 
Hydrid. 

Hydramyl  Ether. — A  local  anesthetic  containing  equal  parts  of  hy- 
dramyl and  ether. 

Hydramyle. — To  quote  Eichardson  (Sci.  Am.  Suppl.,  No.  516, 
8240)  :  "A  mixture  made  by  adding  amyl  hydrid  to  zinc  in  making 
methylene  bichlorid  from  chloroform.  A  colorless  ethereal  fluid.  Sp. 
gr.,  0.720.  Vapor  ethereal,  sweet,  and  very  pleasant  to  breathe;  quan- 
tity required  to  produce  anesthesia,  2  to  4  fluid  drachms.  Action  ex- 
tremely rapid,  complete  insensibility  sometimes  occurring  within  the 
minute.  Peculiar  in  its  effect  in  that  insensibility  from  it  intensifies  for 
a  few  seconds  after  it  is  withdrawn.  Eecovery,  when  it  commences,  al- 
most immediate.  An  excellent  anesthetic  for  short  operations  like  ex- 
traction of  a  tooth.  Was  administered  by  author  forty-six  times  to  the 
human  subject,  with  production  of  insensibility  within  an  average  of 


768  ANESTHESIA 

fifty  seconds,  and  without  vomiting  or  any  other  untoward  symptom." 
Eiehardson  introduced  hydraniyle  in  1871. 

Hydriodic  Ether. — See  Etliyl  lodicl. 

Hydrobromic  Ether. — See  Ethijl  Bromid. 

Hydrochloric  Ether. — See  Ethyl  Chlorid. 

Hyoscin  (or  Hyoscine)  Hydrobromid. — See  Scopolamin  Hydro- 
hromid. 

Hyoscin,  Morphin,  and  Cactin. — On  the  use  of  this  combination  as 
an  anesthetic,  see  Lee:    J.  Minn.  Med.  Assn.,  28,  98. 

Hyoscin-morphin  Mixture. — This  anesthetic  has  been  used  in  ob- 
stetrical medicine  in  a  dose  of  1/100  gr.  of  hyoscin  hydrobromid  and 
1/4  gr.  of  morphin  sulphate.    See  Practitioner,  July,  1911. 

Ice  and  Salt. — Lemke  used  ice  and  salt  to  anesthetize  the  site  of 
the  insertion  of  the  cannula,  previous  to  injecting  nitrogen  in  tubercu- 
lar pulmonary  cavities  (Heineck,  "General  and  Local  Anaesthesia," 
1900,  87).  A  mixture  of  salt  and  snow  was  highly  recommended  by 
Arnott  as  a  local  anesthetic,  but  such  a  method  is  troublesome. 

Ichnol. — An  alcoholic  solution  of  ethereal  oils  (eugenol,  etc.)  col- 
ored green  by  means  of  chlorophyll.    Used  in  odontolgia.     See  Jehnol. 

Idin. — Apparently  spirits  of  camphor.  Used  in  odontalgia.  Ac- 
cording to  Eiedel's  "Mentor"  (1912,  173),  a  solution  of  camphor  and 
menthol,  or  oil  of  peppermint,  in  alcohol. 

Injection  Hirsch. — This  is  said  to  be  a  stable  solution  containing  one 
per  cent  of  mercury  oxycyanid  and  one  half  of  one  per  cent  of  Acoin 
(q.  v.),  used  as  a  local  anesthetic. 

Iodoform. — Iodoform  is  said  to  resemble  the  other  kindred  anes- 
thetics in  its  physiological  action ;  in  the  lower  animals  it  produces  mus- 
cular rigidity,  anesthesia,  sleep,  muscular  relaxation,  and,  in  sufficient 
doses,  death.  It  has  not  received  any  real  consideration  as  an  anes- 
thetic for  operations. 

Iso-amylene-beta-pental. — This  compound  has  been  used  for  effecting 
total  anesthesia. 

Isobutyl  Ester  of  Para-amidobenzoic  Acid. — See  Cydoform. 

Isopon. — This  preparation  contains  the  alkaloids  of  opium.  See 
Pantopon. 

Isopral. — Isopral  (triehlorisopropylalcohol),  CCI3.CHOH.CH3,  is 
obtained  in  prismatic  crystals,  possessing  a  camphoraceous  odor  and 
pungent  taste.  It  has  a  melting  point  of  -f-  49°  C.  It  is  soluble  in 
about  30  parts  of  cold  water,  more  readily  in  alcohol  and  ether.  Isopral 
is  a  hypnotic,  the  uses  of  which  are,  in  general,  those  of  chloral  hydrate. 
The  dose  is  0.3  to  1.3  gm.  (5  to  20  grains).  Mertens  {Arch.  Jclin.  Chir., 
95,  No.  3)  found  isopral  to  be  useful  as  a  preliminary  to  chloroform 
anesthesia  when  given  in  the  form  of  rectal  injections.  Burkhardt 
{Munch,  med.  Woch.,  1911,  No.  15)  employed  isopral  intravenously  as 


A   LIST    OF    ANESTHETICS  7G9 

an  anesthetic,  finding  it  to  possess  several  advantages  over  Tledonal 
(q.  v.).  Intravenous  ether  anesthesia  seems  to  liave  special  advantages 
when  combined  with  isopral  (Burkhardt:  Miinch.  rned.  Woch.,  1911, 
778). 

Jehnol. — A  solution  containing  ethereal  oils  and  camphor,  colored 
green  with  chlorophyll.    Used  in  odontalgia. 

Johimbin. — See  Yohimhin. 

Kandol. — See  Canadol. 

Katharin. — See  Carbon  TetracJdorid. 

Kelen  or  Kelene. — A  purified  ethyl  chlorid,  supplied  in  a  special 
form  of  container.  There  are  also  preparations  of  cocaiji  and  kelene, 
formaldehyd  and  kelene,  and  of  the  latter  with  menthol. 

Kelene-methyl. — A  mixture  of  ethyl  chlorid  with  methyl  chlorid  for 
use  as  an  anesthetic.     See  Z.  angew.  Cliem.,  1901,  261. 

Keroselene. — A  mixture  of  hydrocarbons  from  coal  oil,  possessing  a 
boiling  point  of  -(-  90°  F. ;  it  was  jjroposed  as  an  agent  for  producing 
anesthesia  by  inhalation  (see  Bigelow:  Boston  Med.  and  Surg.  J., 
July  11,  1861),  but  it  produced  in  every  case  disagreeable  and  alarming 
symptoms,  as  irritation  of  the  air  passages,  lividity  of  the  surface,  mus- 
cular disturbance,  and  intermission  of  the  pulse. 

Koenig's  ^ther  Anaestheticus. — See  zEtlier  Ancestheticus  (Koenig). 

Lamellae  Cocainae. — Each  lamella  contains  1/50  gr.  cocain  hydro- 
chlorid. 

Laudanon. — This  is  an  opium  preparation  containing  a  combination 
of  difterent  opium  alkaloids.     See  Pantopon. 

On  laudanon,  see  Faust:     Miinch.  med.  ^Yocll.,  1912,  2189. 

Letargin. — In  each  c.  c.  are  0.5  gm.  extract  hamamelis,  0.015  gm. 
novocain,  0.0092  gm.  sodium  chlorid,  0.0002  gm.  thymol,  0.5  gm.  distilled 
water,  and  1  drop  of  a  1 :  1000  suprarenin  hydrochlorid  solution;  it  is 
used  as  a  local  anesthetic  in  the  extraction  of  teeth  and  in  other  minor 
operations. 

Letheon. — Morton  and  Jackson  sought  to  patent  their  anesthetic 
under  this  name.  It  was  soon  recognized  as  ethyl  ether  (see  Chapter  I, 
p.  16).  It  has  been  stated  that  ethyl  ether  mixed  with  aromatic  oils 
was  termed  "Letheon"  in  1846. 

Linhart's  A.  C.  Mixture. — According  to  Buxton  ("Anaesthetics,"  4th 
ed.,  288),  "Linhart's  Mixture"  is  composed  of  alcohol,  1  part,  and 
chloroform,  4  parts.  Buxton  further  states  {ibid.,  294)  that  it  con- 
tains 20  per  cent  alcohol — more  than  is  necessary — and  gives  less  good 
results  than  the  10  per  cent  mixture.  See  also  Dumont's  "Allgemeine 
u.  lokale  Anaesthesie,"  117. 

Linhart's  C.  E.  Mixture. — A  mixture  of  chloroform,  1  part,  and 
ethyl  ether,  4  parts.  "This  mixture  is  devoid  of  any  danger"  (Miiller: 
"Narkologie,"  1908,  492). 


770  ANESTHESIA 

Liquor  Ansestheticus. — A  very  variable  mixture  obtained  by  chlori- 
nating ethyl  chlorid. 

Liquor  Hollandicus. — See  Ethylene  Clilorid. 

Locasemin. — A  local  anesthetic,  similar  to  Eusemin  (q.  v.). 

Loco-dolor. — A  purified  ethyl  chlorid. 

London  Medical  and  Chirurgical  Society  Mixtures. — A — Alcohol,  1 
part;  chloroform,  2  parts;  ether,  3  parts.  B — Chloroform,  1  part;  ether, 
4  parts.  C — Chloroform,  1  part;  ether,  2  parts.  It  was  found  that 
mixture  B  was  very  isimilar  in  physiological  action  to  ethyl  ether  (see 
Med.  Chir.  Trans.,  Jfl,  1864) ;  that  the  mixtures  A  and  C  were  very 
similar  to  each  other  in  their  action;  that  A  and  C  exercised  a  much 
less  depressing  effect  upon  the  action  of  the  heart  than  chloroform 
alone;  that  a  mixture  of  ether  and  chloroform  (such  as  A  and  C)  was 
as  effective  as  pure  chloroform,  and  a  safer  agent  where  deep  and  pro- 
longed anesthesia  was  to  be  induced.  In  the  opinion  of  the  committee, 
preference  was  to  be  given  to  mixture  A.  Ellis  ("Anaesthesia  with 
Mixed  Vapor,"  London,  1866)  found  that,  when  the  mixture  A  was 
evaporated,  during  the  six  or  seven  minutes  required  for  the  evaporation 
of  half  a  drachm  (two  grams)  of  the  liquid,  the  vapor  of  ether,  almost 
exclusively,  was  given  off  during  the  first  minute,  the  vapor  of  chloro- 
form predominated  during  the  next  three  minutes,  and  the  evaporation 
of  alcohol  occupied  the  last  three  minutes. 

On  death  from  the  inhalation  of  a  mixture  of  chloroform  and  alco- 
hol, see  Hammond:  Am.  J.  Med.  Sci.,  July,  1858,  41;  and  on  death 
from  inhaling  a  mixture  of  chloroform,  ether,  and  alcohol,  see  Morton 
and  Hewson:  Ibid.,  Oct.,  1876,  415.  See  A.  C.  E.  Mixture;  Ancesihol 
(W.  Meyer)  ;  and  ''M.  S." 

Lycoperdon  Proteus. — See  Puff-ball. 

Magnesium  Salts.— In  1906  S.  J.  Meltzer  {Berl.  Jclin.  Woch.,  1906, 
No.  3,  73)  conducted  experiments  with  the  subcutaneous,  intravenous, 
and  intraspinal  injection  of  magnesium  sulphate.  Meltzer  reasoned 
from  the  fact  that  intracerebral  injections  of  magnesium  salts  produced, 
not  convulsions,  but  evidences  of  paralysis.  The  results  of  his  experi- 
ments, which  proved  that  magnesium  sulphate  has  not  an  inconsidera- 
ble anesthetic  action,  decided  Meltzer  to  employ  lumbar  anesthesia  by 
means  of  magnesium  sulphate  in  a  number  of  operations  on  patients, 
partly  by  itself  and  in  part  in  combination  with  the  inhalation  of  chlo- 
roform. He  injected  1  c.  c.  of  a  25  per  cent  sterile  solution  of  mag- 
nesium sulphate  for  each  12  kg.  of  body  weight,  and  found  that  after 
3  or  4  hours  there  appeared  paralysis  of  the  legs  and  the  region  of  the 
pelvis,  thus  permitting  of  the  painless  performance  of  an  operation  in 
these  regions.  Meltzer  observed,  as  secondary  actions,  undue  prolonga- 
tion of  the  paralysis  and  retention  of  the  urine,  but  reported  that  these 
could  be  avoided  by  washing  out  the  spinal  canal  with  normal  saline 


A   LIST   OF    ANESTHETICS  771 

solution.  The  heart  and  blood  pressure  were  said  to  be  unaffected,  but 
the  influence  on  the  respiration  required  careful  notice. 

Desguin  (Deut.  Med.-Zig.,  1907,  No.  99,  1102)  reported  on  the 
innocuous  nature  of  magnesium  sulphate  as  leading  to  its  adoption  in 
the  place  of  the  customary  anesthetics  in  certain  cases;  and  Tucker 
{Therap.  Gaz.,  1907,  No.  5;  Revista  espec.  medicas,  1907,  No.  199, 
475;  Merck's  Archives,  1907,  No.  6,  178)  applied  solutions  of  mag- 
nesium sulphate  as  local  anesthetics. 

Delhaye  {Presse  med.,  1908,  397)  studied  the  anesthetic  action  of 
magnesium  salts  from  a  pharmacological  standpoint.  He  regarded 
these  salts  as  strong  nerve  sedatives,  able  to  produce  complete  anesthe- 
sia and  even  paralysis.  They  have,  according  to  Delhaye,  no  toxic  ac- 
tion on  the  heart,  although  he  considered  them  dangerous  to  respiration 
and  to  the  kidneys,  and  that  they  should  not  be  employed  for  producing 
anesthesia  for  these  reasons.  Netter  (J.  de  Med.  inter.,  1909,  38)  and 
Griffon  and  Lian  {These  de  Paris,  1908)  noted  the  anesthetic  power  of 
solutions  of  magnesium  sulphate,  particularly  on  subcutaneous  or  intra- 
venous application.     Henderson    (J.  Pharmacol,   and  Exper.   Therap., 

1909,  1,  199)  investigated  the  production  of  anesthesia  by  intracerebral 
injection  of  magnesium  chlorid.  More  recently  the  use  of  magnesium 
sulphate  as  an  anesthetic  has  been  described  by  Corrado :    II  PolicUnico, 

1910,  124;  but  especially  Rev.  de  Therap.,  1910,  No.  16,  556;  Phillips: 
Klin.-therap  Woch.,  1910,  No.  10,  263;  Johnson:  Brit.  Med.  J.,  1910, 
No.  2590,  457;  Paterson:  Lancet,  1910,  No.  4518,  922;  and  Canestro: 
Klin.-therap.  Woch.,  1910,  No.  19,  455.  Canestro  found  that  the  spinal 
anesthesia  produced  by  magnesium  sulphate  caused  no  changes  in  the 
central  nervous  system  such  as  had  been  observed  to  follow  the  use  of 
other  anesthetics.  Hyndham  and  Mitchener  (J.  Am.  Med.  Assn.,  July 
23,  1910)  proved  that  magnesium  sulphate  injections  paralyzed  only 
the  sensory  cells  and  not  the  motor  cells  of  the  cerebral  centers.  The 
value  of  magnesium  sulphate  in  the  treatment  of  tetanus  is  apparently 
well  established;  it  depends  upon  the  sedative  action  of  the  salt,  which 
persists  long  enough  to  enable  the  brain  to  render  the  tetanus  poison 
harmless. 

Guthrie  and  Ryan,  in  a  paper  on  the  reported  specific  anesthetic 
property  of  magnesium  salts  {Am.  J.  Physiol.,  26,  329),  claim  that  the 
specific  anesthetic  properties  cannot  be  ascribed  to  magnesium  salts, 
despite  the  assertions  of  Meltzer  and  others  to  the  contrary. 

Wiki  {Arch,  intern.  Pharmacodyn.,  21,  415)  studied  the  local  anes- 
thetizing action  of  magnesium  sulphate.  He  was  able  to  confirm  the 
local  anesthetizing  effect  and  to  show  that  the  action  is  augmented  with 
the  concentration  of  the  solution. 

Meltzer  has  more  recently  injected  magnesium  sulphate  (1  c.  c.  of  a 
25  per  cent  solution  in  sterile  water  per  kg.  of  animal)  into  the  femoral 


772  ANESTHESIA 

muscle,  and  thereby  obtained  great  relaxation  with  much  smaller 
amounts  of  ether.  The  animal  is  first  anesthetized  with  ether  by  the 
cone  method,  and  the  solution  injected,  the  infiltrated  muscle  being  im- 
mediately massaged  thoroughly.  By  giving  calcium  salts  Just  before  the 
ether  is  discontinued,  the  subject  is  brought  quickly  from  under  the  in- 
fluence of  the  magnesium. 

Maier's  Radikal-anasthetikum. — See  Radilcal-andstlietihum  Maier. 

Mannin. — Amido-oxybenzoic  acid  methyl  ester,  a  local  anesthetic. 

Martindale's  Mixture. — A  volumetric  mixture,  the  ingredients  of 
which  are  said  to  evaporate  almost  uniformly.  It  is  composed  of  ab- 
solute alcohol  (0.795),  1  volume;  chloroform  (1.497),  3  volumes;  and 
ethyl  ether  (0.720),  3  volumes.  See  A.  C.  E.  Mixture,  from  which  Mar- 
tindale's mixture  differs  only  in  the  specific  gravity  of  the  ingredients 
and  from  the  fact  that  "the  three  ingredients  are  intended  to  evaporate 
uniformly."  There  is  said  to  be  no  advantage  in  this  mixture  over  the 
A.  C.  E.  mixture,  and,  since  the  specific  gravities  mentioned  in  either 
differ  from  those  for  the  corresponding  anesthetics  used  in  the  United 
States,  the  A.  C.  E.  mixture  may  be  defined  as  alcohol,  1  part;  chloro- 
form, 3  parts ;  and  ether,  3  parts ;  the  best  quality  of  ingredients  to  be 
employed  and  the  mixture  freshly  prepared. 

On  Martindale's  mixture,  see  "The  Extra  Pharmacopoeia,"  by  Mar- 
tindale  and  Westcott,  12th  ed.,  235;  and  Hewitt's  "Anaesthetics  and 
Their  Administration,"  3rd  ed.,  467. 

Med.  Chir.  Soc.  of  London's  Mixture.  See  A.  C.  E.  Mixture,  and 
London  Medical  and  Chirurgical  Society  Mixtures. 

Menthol  Thymate. — Used  in  odontalgia. 

Menthophenol. — An  aromatic  liquid,  soluble  in  alcohol,  ether,  and 
chloroform,  but  not  in  water  or  glycerin,  obtained  by  fusing  3  parts  of 
menthol  with  1  part  of  phenol;  it  possesses  antiseptic  and  analgesic 
properties. 

Menthophenol  Cocain. — A  local  anesthetic,  obtained  by  fusing  equal 
parts  of  menthol,  crystalline  phenol,  and  cocain  hydrochlorid,  also 
known  as  Bonaine  (q.  v.). 

Von  Mering's  Mixture. — A  mixture  of  chloroform,  1  part,  and  di- 
methylacetal,  2  parts  (Dumont:  "Allgemeine  u.  lokale  Ana^sthesie," 
117).     See  DimethyJacetal. 

Metsethyl. — This  mixture  of  ethyl  and  methyl  chlorids  is  mentioned 
in  Z.  angctr.  Cliem.,  1901,  2G1.     See  Methethyl 

Methaform. — Methaform,  known  also  as  acetone-chloroform,  chlor- 
butanol,  and  dimethylcarbinol  chloroform,  is  a  white,  crystalline  com- 
pound possessing  a  camphor-like  taste  and  odor.  It  occurs  in  delicate 
needle-like  crystals,  sparingly  soluble  in  water,  but  quite  soluble  in 
chloroform,  alcohol,  ethyl  ether,  and  glacial  acetic  acid.  Water,  at  the 
ordinary  room  temperature,  dissolves  about  1  part  in  100.     Methaform 


A   LIST    OF    ANESTHETICS  773 

is  not  decomposed  by  acids  or  alkalies.  It  melts  at  +  9G°  to  97°  C, 
boils  at  +  167°  C,  and  sublimes  at  body  temperature  in  characteristic 
crystals. 

Methaform  is  hypnotic,  analgesic,  anesthetic,  and  antiseptic.  In 
physiological  action  it  closely  resembles  chloral  hydrate,  ])ut  is  said  to 
be  less  likely  to  irritate  the  stomach  and  to  exert  a  less  depressant  ac- 
tion on  the  circulation.  In  addition,  it  is  said  to  paralyze  the  sensory 
nerve  terminals  when  applied  locally,  and  hence,  like  cocain,  to  be  ap- 
plicable for  local  anesthesia,  especially  in  infiltration  anesthesia.  In 
experimental  work  upon  the  lower  animals,  where  anesthesia  is  desired, 
it  is  said  that  methaform  is  almost  an  ideal  anesthetic  when  adminis- 
tered in  doses  of  2  to  5  grains  per  pound  weight  of  the  animal. 

Cocain  hydrochlorid  solution  with  methaform  (3  per  cent  and  4 
per  cent  cocain)  is  offered  in  1  ounce  vials.  It  is  said  that  methaform, 
being  strongly  antiseptic  as  well  as  a  local  anesthetic,  is  perhaps  the 
best  preservative  for  cocain  solutions.  It  is  reported  to  not  only  pre- 
vent decomposition  of  the  cocain,  thus  rendering  the  solution  stable,  but 
to  be  a  material  aid  in  the  production  of.  anesthesia.  It  is  furthermore 
said  to  be  of  value  in  preventing  infection  of  the  tissues  by  the  hypo- 
dermic needle  employed  to  introduce  the  cocain  solution.  Cocain  solu- 
tions with  methaform  are  said  to  be  of  value  in  flental  and  other  minor 
surgical  operations.     See  CMoretone. 

Methane. — T.  Nunneley,  in  1849,  and  Richardson,  in  18G7,  intro- 
duced methane  as  an  anesthetic.  Eichardson  found  it  to  be  "a  very 
good  anesthetic,  but  not  practical,  owing  to  ics  being  a  gas"  (Sci.  Am. 
Suppl.,  ISTo.  51G,  8240).  He  found  that  it  could  be  breathed  without 
irritation;  that  the  quantity  required  in  air  for  anesthesia  was  35  per 
cent;  and  that  the  anesthesia  was  slowly  induced  without  any  active 
spasmodic  stage. 

Methenyl-o-Anisidin. — According  to  Goldschmidt  (Cheni.  Ztg.,  25, 
329),  this  compound  possesses  anesthetic  properties;  its  guaiacol  sul- 
phonic  acid  salt  also  has  an  anesthetic  action. 

Methenyl-p-Phenetidin. — A  local  anesthetic. 

Methethyl. — A  mixture  of  ethyl  and  methyl  chlorids,  used  as  a  spray 
for  producing  local  anesthesia. 

Methoxycaffein. — This  compound  [CgH9(0CH3)I^^0o]  is  a  white 
bulky  powder,  melting  at  -|-  177°  C,  and  slightly  soluble  in  water,  more 
readily  soluble  in  dilute  ak'ohol.  It  is  used  subcutaneously  as  a  local 
anesthetic  (1  c.  c.  of  a  2  per  cent  solution). 

Methyl  Acetylsalicylate. — Pototzky  (Arch,  de  Pliarmacodyn.,  12, 
132)  found  this  ester  to  possess  local  anesthetic  properties. 

Methyl  Alcohol. — B.  W.  Richardson  introduced  methyl  alcohol  as 
an  anesthetic  in  1867.  He  found  that  the  vapor  was  pungent  to  breathe 
and  slightly  provocative  of  coughing.     The  quantity  of  liquid  required 


774  ANESTHESIA 

for  complete  anesthesia  was  from  li/o  to  2  ounces  by  volume,  and  the 
required  charge  of  air  was  to  saturation.  The  action  was  very  slow, 
and  with  distinct  symptoms  of  alcoholic  intoxication;  a  full  hour  was 
required  to  produce  insensibility,  which  at  the  deepest  was  insuthcient 
to  destroy  reflex  irritability.  The  breathing  was  stertorous,  often  with 
bronchial  rales;  the  recovery  was  very  slow,  being  four  to  six  hours  in 
deep  anesthesia;  and  the  temperature  was  reduced  3°  F.  Eichiardson 
regarded  methyl  alcohol  as  an  indifferent  anesthetic,  owing  to  the  length 
of  administration  and  slow  recovery,  but  considered  the  danger  prac- 
tically nil.  He  learned  that  when  the  inhalation  was  enforced  to  the 
production  of  death,  the  circulation  and  respiration  ceased  simultane- 
ously (Sci.  Am.  Suppl.,  No.  516,  8240). 

The  use  of  methyl  alcohol  as  an  anesthetic  is  highly  objectionable. 
Methyl  alcohol  is  less  poisonous  to  lower  plants  and  infusoria  than  ethyl 
alcohol,  but  for  higher  animals,  and  especially  for  man,  it  is  a  severe 
toxic  agent.  It  occasions  toxic  effects  whether  it  is  taken  internally  or 
inhaled  through  the  lungs.  Methyl  alcohol  is  treated  fully  by  Basker- 
ville  in  his  report  to  the  State  Factory  Investigating  Commission  of 
New  York,  1913,  which  should  be  consulted. 

Methyl  Bromid. — B.  W.  Eichardson  introduced  this  compound  as  an 
anesthetic  in  1867.  He  found  the  physiological  properties  to  be  an- 
alogous to  those  of  Ethyl  Bromid  (q.  v.),  but  causing  more  irritation, 
with  salivation.  The  anesthetic  value  was  stated  by  Eichardson  {Sci. 
Am.  Suppl.,  No.  516,  8240)  to  be  analogous  to  that  of  ethyl  bromid, 
but  less  practical,  owing  to  the  extreme  volatility  and  lesser  steadiness 
of  action.    Methyl  bromid  is  only  slightly  toxic. 

Methyl  Chlorid  (Methyl  Chloridum).— Methyl  chlorid  (CH3CI)  is 
the  hydrochloric  acid  ester  of  methyl  alcohol.  It  occurs,  in  the  com- 
pressed state,  as  a  colorless  liquid,  having  an  ethereal  odor  and  a  sweet 
taste. 

Methyl  chlorid  is  insoluble  in  water,  more  readily  in  alcohol,  freely 
in  ether  and  chloroform,  and  also  in  acetic  acid.  It  should  be  neutral  to 
litmus  paper.  At  about  —  25°  C.  (  —  13°  F.),  it  has  a  specific  gravity 
of  0.991,  and  boils  at  about  —  21°  C.  (  —  5.8°  F.).  It  burns  in  the  air 
with  a  greenish  flame,  though  it  is  not  highly  inflammable.  The  neutral 
solution  is  not  precipitated  by  a  solution  of  silver  nitrate,  nor  is  there 
any  reaction  with  potassium  iodid  and  starch  paste.  If  the  liquid  is 
allowed  to  evaporate  it  is  a  powerful  refrigerating  agent.  At  very  low 
temperatures  it  forms  with  water  a  hydrate,  CH3CI.9H2O.  It  should  not 
react  alkaline  to  litmus  (absence  of  ammonia  and  methylated  ammonia 
— methylamin).  It  should  not  immediately  form  a  precipitate  with  sil- 
ver nitrate.  On  evaporating  it  should  leave  no  residue  and  emit  no 
odor  of  methylamin. 

Action  and  Uses. — By  its  evaporation  a  temperature  of  —  23°   C. 


A    LIST    OF    ANESTHETICS  775 

(  —  9.4°  F.)  is  produced,  while  if  the  evaporation  is  accelerated  by 
means  of  a  current  of  air  a  temperature  of  —  55°  C.  (  —  67°  F.)  may 
easily  be  reached.  On  account  of  this  property,  it  is  used  as  a  local  an- 
esthetic in  the  form  of  a  spray,  but  its  use  requires  caution,  since  it  is 
apt  to  produce  blisters.  The  diluted  vapor  is  said  to  be  non-poisonous. 
Methyl  chlorid  is  said  to  be  an  efficient  general  anesthetic,  which  has 
practically  no  influence  on  the  circulation,  but  fails  to  produce  com- 
plete muscular  relaxation.  It  is  used  as  a  general  anesthetic,  mixed 
with  ethyl  chlorid  and  ethyl  bromid.  Eichardson  introduced  it  as  a 
general  anesthetic  in  1867.  He  found  the  gas  very  pleasant  to  breathe, 
and  determined  the  required  charge  of  air  to  be  15  per  cent.  The  an- 
esthetic action  was  found  to  be  rapid  and  most  effective,  with  the  brief- 
est spasmodic  stage  or  with  no  such  stage  at  all;  insensibility  was  deep, 
and  recovery  was  rapid,  not  being  longer  than  five  minutes  from  the 
deepest  narcotism,  and  with  no  bad  after-effects.  Vomiting  was  rare. 
Eichardson  (Sci.  Am.  Suppl.,  No.  516,  8240)  considered  it  one  of  the 
best  and  safest  of  anesthetics — the  safest  of  all  anesthetics  containing 
chlorin,  but  difficult  of  management,  owing  to  it  being  a  gas.  When 
carried  to  the  point  of  death,  the  heart  was  found  to  outlive  the  respira- 
tion, and  the  muscles  to  retain  their  irritability  after  death  for  periods 
of  three  to  four  hours.  The  heart  pulsated  spontaneously,  in  the  case 
of  a  rabbit  killed  by  the  vapor,  for  forty  minutes. 

Methyl  Chlorid  is  less  toxic  than  Methylene  Chlorid  (q.  v.). 
Eichet  and  Marcille  (Sem.  med.,  1902)  reported  that  methyl  chlorid 
acted  on  the  animal  as  an  efficient  anesthetic  and  that  it  had  practically 
no  influence  on  the  circulation. 

Dosage. — When  sprayed  on  tLe  skin,  the  part  should  be  partly  pro- 
tected by  a  thin  layer  of  cotton  wool.  When  used  locally,  cotton  wool 
soaked  in  liquid  methyl  chlorid  may  be  applied  to  the  skin  over  the 
painful  area,  but  care  should  be  taken  that  blisters  are  not  formed.  In 
order  to  avoid  this,  a  mixture  with  ethyl  chlorid  has  been  recommended. 

Methyl  Chlorid-Alcohol. — The  Committee  of  the  British  Medical 
Association  {Brit.  Med.  J.,  Jan.  4,  1879)  reported  that  methyl  chlorid, 
liberated  from  its  alcoholic  solution,  was  not  very  potent.  A  rabbit  was 
subjected  to  its  inhalation,  but  ^^after  somewhat  prolonged  use  there 
was  not  any  abolition  of  reflex  action,  and  the  animal  almost  immedi- 
ately recovered.     The  only  effect  was  slight  drowsiness." 

Methyl  Chlorid-Ether. — Hermann  and  Eichardson  found  the  solu- 
tion of  methyl  chlorid  in  ether  to  be  a  very  efficient  and  agreeable  an- 
esthetic. 

Methyl  Chloroform. — See  Trichlorethane. 

Methyl  Cinnamenylacrylate. — Pototzky  (Arch,  de  Pharmacodyn., 
12,  132)  found  that  this  ester  had  local  anesthetic  properties. 

Methyl  Dichlorid  (Methyl  Bichlorid,  Eichardson-Merck) . — A  mix- 


776  ANESTHESIA 

ture  of  1  volume  of  methyl  alcohol  and  4  volumes  of  chloroform  for 
anesthesia  by  inhalation.  Not  to  be  confounded  with  Methylene 
Bichlorid. 

Methyl  Ether  (Dimethyl  Ether;  Methyl  Oxid).— This  anesthetic 
gas  has  been  sold  in  ethereal  solution,  but  is  not  used  in  the  United 
States.  It  was  introduced  by  Eichardson  as  an  anesthetic  in  1867.  He 
found  the  gas  pleasant  to  breathe,  causing  no  irritability.  The  required 
charge  of  air  was  25  per  cent.  The  anesthetic  action  was  rapid  up  to 
complete  insensibility,  without  any  manifestation  of  a  spasmodic  stage; 
in  fact,  Eichardson  found  that  methyl  ether  possessed  the  remarkable 
property  of  destroying  sensibility  before  destroying  consciousness.  The 
recovery  from  deep  anesthesia  was  rapid,  and  was  unattended  by  any 
bad  symptom  or  vomiting.  TJie  temperature  was  reduced  1°  to  2°  F. 
in  deep  anesthesia.  To  quote  Eichardson  {Sci.  Am.  Suppl.,  No.  516, 
8240)  :  "I  consider  methylic  ether  to  be  the  safest  of  all  anesthetics 
hitherto  discovered.  Pigeons  and  rabbits  will  remain  anesthetized  in  a 
full  anesthetic  atmosphere  for  twelve  minutes  without  dying,  and  after 
being  allowed  to  die  are  recoverable  by  artificial  respiration  seven  min- 
utes after  cessation  of  all  signs  of  life.  The  one  practical  objection  to 
methylic  ether  as  an  anesthetic  consists  in  it  being  a  permanent  gas  at 
ordinary  temperatures.  I  have  administered  it  successfully  twenty-seven 
times  to  the  human  subject." 

According  to  Francis  and  Fortescue-Brickdale  ("The  Chemical 
Basis  of  Pharmacology,"  1908,  104),  methyl  ether  acts  very  like  nitrous 
oxid,  producing  a  rapid  and  transient  anesthesia.  The  same  authors 
call  attention  to  the  fact  that  it  would  be  interesting  to  ascertain 
whether  methyl-ethyl  ether  (CFIo.O.OoHg)  has  any  advantages  over 
ordinary  ethyl  ether. 

On  the  properties  of  methyl  ether,  see  J.  Pharin.  Cliim.  (4),  19,  438. 

Methyl  Fluorid. — Moissan  stated  that  methyl  fluorid  possessed  an- 
esthetic properties  {Bull,  de  I' Acad,  de  Med.  de  Pmis,  1890). 

Methyl  Hydrate  or  Hydroxid. — See  Methyl  Alcohol. 

Methyl  lodid. — This  compound  was  experimented  with  by  Eichard- 
son and  Simpson,  who  found  that  its  vapor  could  be  respired,  even  to 
the  induction  of  anesthesia.  Simpson  regarded  it  as  powerful  but  dan- 
gerous.    It  has  also  been  employed  as  a  local  anesthetic. 

Methylal  (Methylene-dimethyl  Ester;  Formal;  Methylene  Dimethy- 
late). — This  compound  [CHo(0CH3)2],  prepared  by  distilling  together 
methyl  alcohol,  water,  sulphuric  acid,  and  manganese  dioxid,  is  a  color- 
less volatile  liquid  with  a  chloroform-like  odor  and  a  pungent  taste;  it 
possesses  a  density  of  0.855  at  -\-  15°  C,  and  boils  at  -|-  42°  C;  it  is 
easily  soluble  in  water,  alcohol,  and  oils.  At  the  present  time  it  is  said 
to  be  used  as  a  10  per  cent  liniment  or  ointment  as  a  local  anesthetic. 
Eichardson  introduced  methylal  as  an  anesthetic  in  1868.     He  found 


A   LIST    OF    ANESTHETICS  777 

that  its  anesthetic  value  was  the  same  as  that  of  Methyl  Alcohol  (q.  v.) ; 
that  its  vapor  was  agreeable  to  breathe,  and  that  the  quantity  required 
to  produce  anesthesia  was  from  1  to  3  fluid  ounces,  the  required  charge 
of  vapor  in  air  being  35  per  cent.  "Kecovery  very  prolonged,  but  with- 
out painful  symptoms  or  vomiting"  (Sci.  Am.  Suppl.,  No.  516,  8240). 
According  to  Francis  and  Fortescue-Brickdale  ("The  Chemical  Basis 
of  Pharmacology,"  1908,  104),  methylal  produces  anesthesia  slowly; 
the  action  is  prolonged  and  deep,  but  somewhat  uncertain;  and  patients 
quickly  become  accustomed  to  it. 

"Methylene." — ^A  mixture  of  methyl  alcohol,  30  per  cent  (1  vol- 
ume) ;  and  chloroform,  70  per  cent  (4  volumes),  proposed  by  Eegnault 
and  Villejean.  It  is  said  to  be  inferior  to  and  less  safe  than  alcohol- 
chloroform  mixture,  1:10,  and  is  seldom  used  at  the  present  time. 

"Methylene  Bichlorid." — See  Narcotil. 

Methylene  Chlorid  (Methylene  Bichlorid;  Dichloromethane ;  Meth- 
ene  Chlorid). — This  compound  (CH2CI2)  is  prepared  by  the  action  of 
zinc  and  hydrochloric  acid  on  a  mixture  of  alcohol  and  chloroform; 
it  is  a  colorless  liquid  which  possesses  a  density  of  1.377  at  -\-  15°  C, 
and  a  boiling  point  of  -f-  40°  C.  It  is  soluble  in  alcohol  and  ethyl 
ether.  It  is  used  in  the  form  of  a  spray  to  produce  local  anesthesia, 
particularly  in  dental  surgery. 

Eichardson  introduced  methylene  chlorid  as  a  general  anesthetic  in 
1867.  He  reported  that  the  vapor  was  pleasant  to  inhale  and  was  not 
irritating;  that  the  quantity  of  liquid  required  to  produce  anesthesia 
was  1  to  6  fluid  drachms;  that  the  required  charge  of  air  was  5  to  10 
per  cent;  that  the  action  was  rapid,  with  short  but  rather  acute  spas- 
modic stage;  and  that  insensibility  was  perfect.  He  found  recovery 
to  be  rapid,  and  usually  without  bad  symptoms;  that  vomiting  occurred 
about  once  in  six  administrations;  and  that  the  animal  temperature  was 
reduced  from  2°  to  3°  F.  under  deep  anesthesia.  To  quote  the  con- 
clusions of  Eichardson  (Sci.  Am.  Suppl.,  No.  516,  8240)  :  "Pure  meth- 
ene  chlorid  is  one  of  the  best  anesthetics,  but  not  free  from  danger. 
The  deaths  from  it  have  been  estimated  at  1  in  7,000  administrations." 
Eegnault  and  Villejean  (Compt.  rend.,  100,  1146)  reported  that  methy- 
lene chlorid,  like  carbon  tetrachlorid,  but  unlike  chloroform  and  methyl 
chlorid,  exerted  a  poisonous  action  when  inhaled.  See,  however,  Carbon 
Tetrachlorid.  Methylene  chlorid  is  said  to  be  less  toxic  than  chloroform 
(Francis  and  Fortescue-Brickdale's  "The  Chemical  Basis  of  Pharmacol- 
ogy," 1908,  95).    It  cannot  yet  be  regarded  as  a  safe  anesthetic. 

For  cases  of  death  from  the  inhalation  of  methylene  dichlorid,  see 
Brit.  Med.  J.,  Oct.  23,  1869;  ibid..  May  7,  1870;  ibid.,  April  29,  1871; 
ibid.,  Sept.  16,  1871;  ibid.,  Aug.  31,  1872;  ibid.,  Oct.  12,  1872;  ibid., 
Oct.  19,  1873;  Lancet,  Dec,  1874;  Brit.  Med.  J.,  July  24,  1875;  Med. 
Times  and  Gaz.,  Sept.  22,  1877;  iUd.,  June  23,  1877;  and  Brit.  Med. 


778  ANESTHESIA 

J .,  March  2,  1878.  While  Morgan  used  this  agent  1,800  times  without 
a  single  accident  (Brit.  Med.  J.,  Jan.  4,  1879),  it  will  thus  be  seen 
that  others  have  been  less  fortunate. 

Methylene  Ether. — A  mixture  of  equal  parts  of  absolute  ether  and 
methylene  bichlorid  (Richardson,  1870).  Eichardson  (Sci.  Am.  Suppl., 
No.  516,  8240)  described  methylene  ether  as  a  colorless  fluid,  "more 
stable  than  the  other  anesthetic  mixtures,"  the  vapor  of  which  was  pleas- 
ant to  inhale.  He  found  that  the  quantity  required  for  complete  anes- 
thesia was  2  to  8  fluid  drachms;  that  the  action  was  steady  and  rapid, 
with  a  very  slight  spasmodic  stage;  and  that  recovery  was  quick,  with 
few  bad  after-effects,  and  vomiting  infrequent.  To  quote  his  conclu- 
sions :  "An  exceedingly  good  combination  and  deserving  a  further  trial 
than  it  has  received.  Author  administered  it  thirty  times  with  most 
satisfactory  results.  One  death  occurred  in  the  practice  of  Mr.  Law- 
son  Tait,  from  administration  of  a  fluid  supposed  to  be  this  mixture, 
but  which  contained  choloroform  in  large  proportion.  In  death  of  lower 
animals  in  this  vapor,  circulation  survives  respiration."  On  methylene 
ether,  see  also  Richardson :  Med.  Times  and  Gaz.,  1872,  2 ;  and  1873,  1. 
For  cases  in  which  death  occurred  during  its  administration,  see  Phila. 
Med.  Times,  S,  718;  Med.  Times  and  Gaz.,  July  5,  1873;  and  Brit. 
Med.  J.,  March  2,  1878,  290. 

Methylethyl. — A  mixture  of  methyl  and  ethyl  chlorids.  See  Meth- 
ethyl. 

Methylic-Ethylic  Ether. — A  mixture,  proposed  by  Richardson  in 
1867,  made  by  saturating  ethyl  ether  with  methyl  ether  gas.  It  was 
described  by  Richardson  (Sci.  Am.  Suppl.,  No.  516,  8240)  as  a  color- 
less fluid,  very  unstable  and  inflammable,  possessing  a  density  of  0.720. 
He  reported  that  it  was  found  to  be  extremely  pleasant  to  inhale  and 
that  it  showed  all  the  effects  of  methyl  ether,  except  that  anesthesia  was 
slower  and  more  prolonged.  "Would  be  among  the  most  valuable  of  an- 
esthetics if  it  were  more  stable  and  practical  in  application." 

ITethyliuin  Bichloratum  Richardson. — See  Methylene  Ether. 

Methylium  Oxyamidobenzoicum. — Para-Amido-m-oxybenzoic  acid 
methyl  ester,  a  local  anesthetic. 

Methylpropylcarbinolurethane. — See  Hedonal. 

Midy's  Mixture. — This  is  described  as  a  solution  of  5/100  gram  of 
subcutin,  1/10  gram  of  mercuric  iodid,  1/10  gram  of  sodium  iodid, 
2/100  gram  of  sodium  chlorid,  and  distilled  water  to  make  1/100  c.  c. 

Molecular  Solution  or  Molecular  Solution  Mixture. — See  "M.  S." 

Monobromethane. — See  Ethyl  Bromid. 

Monochlorethane. — See  Ethyl  Chlorid. 

Monochloro-Ethylene  Chlorid. — See  Ethylene  (Monochloro-)  Chlorid. 

Morphin  Hydrochlorid. — This  compound  has  been  employed  as  a 
local  anesthetic  with  ether  spray  and  for  general  anesthesia  with  chloro- 


A   LIST    OF    ANESTHETICS  779 

form  vapor.  Pitha  stated  (Wiener  med.  ]Yoch.,  18G1,  25,  3(J)  that,  hav- 
ing unsuccessfully  attempted  for  two  hours  to  anesthetize  a  patient,  first 
with  a  mixture  of  ether  and  chloroform,  and  then  with  chloroform 
alone,  he  finally  inserted  into  the  rectum  a  solution  of  the  extract"  of 
belladonna;  the  patient  passed  into  a  condition  of  anesthesia  which  per- 
sisted for  twelve  hours.  In  1863  Nussbaum  found  that,  by  the  hypo- 
dermatic injection  of  morphin  at  the  commencement  of  inhalation,  the 
anesthesia  produced  by  chloroform  could  be  prolonged  for  several  hours. 
In  this  connection,  see  also  Uterhart:  Berl.  Min.  Woch.,  1868,  No.  32. 
Bernard  ("Legons  sur  les  Anaesthesiques,"  Paris,  1875)  collected  a 
large  number  of  cases,  illustrating  the  advantages  connected  with  the 
combined  administration  of  opiates  and  chloroform.  As  a  result  of  his 
experiments  in  treating  the  same  patients,  sometimes  with  chloroform 
alone,  and  sometimes  with  chloroform  and  morphin,  making  an  injec- 
tion about  twenty  minutes  or  half  an  hour  before  the  operation,  Kap- 
peler  ("Ansesthetica,"  209)  concluded  that  the  course  of  the  resulting 
anesthesia  did  not  materially  vary  under  either  set  of  conditions;  he 
believed,  however,  that  the  character  of  the  anesthesia  was  more  tran- 
quil, and  that  the  patient  passed  more  rapidly,  and  with  less  excite- 
ment, into  the  stage  of  insensibility.  See  Scopolamin  Hydrohromid  and 
Pantopon. 

"M.  S."  (Molecular  Solution)  .—Weidig  found  that  119.5  gm.  of 
"chemically  pure"  chloroform  and  74  gm.  of  absolute  ether,  or,  expressed 
in  volume,  43.25  parts  of  chloroform  and  56.75  parts  of  ether,  mixed 
together,  entered  into  '^chemical  combination,"  representing  a  new  an- 
esthetic. To  quote  Meyer  (J.  Am.  Med.  Assn.,  Peb.  29,  1903)  :  "It 
contains  neither  free  ether  nor  free  chloroform  and  has  a  boiling  point 
of  its  own  at  +  125.6°  P.  (  +  52°  C).  We  called  this  product  molecu- 
lar solution  (of  chloroform  and  ether)  or,  abbreviated,  'M.  S.' "  In  the 
first  part  of  1898  Meyer  administered  "M.  S."  for  general  anesthesia 
and  found  it  to  be  an  excellent  narcotic.  It  was  used  by  a  num- 
ber of  surgeons  at  the  German  Hospital  in  New  York  City  in  1903. 
Por  a  discussion  of  the  chemistry  of  "M.  S.,"  see  Anesthol 
(Meyer). 

Mylocal. — A  solution  containing  cocain  and  antiseptics,  for  use  as 
a  dental  local  anesthetic. 

Nalicin. — A  local  anesthetic  for  dental  purposes ;  it  consists  of  1  gm. 
trinitrin  and  1  gm.  of  cocain  hydrochlorid  in  100  gm.  of  a  mixture  of 
spiritus  thymolic  comp.,  alcohol,  sodium  chlorid,  phenol,  formaldehyd, 
and  water. 

Narcoform. — Said  to  be  a  mixture  of  ethyl  chlorid,  60  parts ;  methyl 
chlorid,  35  parts;  and  ethyl  bromid,  5  parts,  which  is  the  original 
soemnoform  formula  of  Eolland  (see  Somnoform)  but  this  cannot  be 
definitely  asserted. 


780  ANESTHESIA 

Narcophin. — Narcophin,  described  as  narcotin-morphin  meconate, 
has  been  considered  in  tlie  following  contributions: 

Straub:     Biochem.  Z.,  Jfl,  419;  Miinch.  med.  Woch.,  1913,  1542. 

Schlimpert :   Munch,  med.  Woch.,  1912,  1544. 

Zehbe:    7&^c^.,  1912,  1543. 

Hermann:    Biochem.  J.,  39,  216, 

V.  Issekutz :    Pflugers  Arch.,  lJf5,  415. 

Caesar:   Biochem.  Z.,  ^2,  ISTo.  4. 

Zweifel:    Monats.  Geburtsh.  u.  Gyn'dk.,  36;  Erg'dnzungsh.,  1912. 

von  Stalewski:    Therap.  d.  Gegenw.,  1912. 

Narcosin. — A  dental  local  anesthetic  which  contains  extract  of  ham- 
amelis  bark  of  high  tannin  content,  "obtained  by  a  peculiar  process  in 
an  autoclave"  (Eiedel's  "Mentor,"  1912,  186).. 

Flury  {Z.  angew.  Chem.,  26,  242)  states  that  "Narkosin"  is  extract 
of  hamaraelis  containing  narcotics. 

Narcotil  (Narkotil)  or  Narcotile. — This  inhalation  anesthetic,  also 
known  as  "Methylene  Bichlorid,"  consisted  of  a  mixture  of  methjd  and 
ethyl  chlorids.  It  was  described  as  a  colorless,  very  volatile  and  inflam- 
mable fluid,  emitting  a  pleasant  odor;  and  was  said  to  be  obtained  by 
the  action  of  hydrochloric  acid  upon  a  mixture  of  ethyl  and  methyl  al- 
cohol. It  was  recommended  by  Eastham  {Lancet,  1903,  No.  4155,  1091) 
for  general  anesthesia,  and  was  administered  with  the  aid  of  Junker's 
inhaler,  narcosis  being  effected  within  one  minute.  It  was  said  that 
return  to  consciousness  was  not,  as  a  rule,  attended  by  headache,  giddi- 
ness, or  other  unpleasant  concomitants;  but  nevertheless  the  sale  of  the 
preparation  was  discontinued  several  years  ago,  as  there  were  certain 
objections  to  its  employment.  According  to  Chem.  Centr.,  1903,  2, 
307,  "Narcotil"  was  a  name  used  in  England  for  "Methylene  Chlorid" 
(q.  v.). 

Narkose-Gemisch  "Dr.  Hirschlaff." — Each  c.  c.  contains  0.05  gm. 
morphosan  (morphin  brommethylate)  and  0.00015  gm.  euscopol,  dissolved 
in  distilled  water.    It  is  offered  to  the  trade  in  sterilized  ampoules. 

Nealpon. — Flury  (Z.  angew.  Chem.,  26,  242)  states  that  this  prep- 
aration contains  the  alkaloids  of  opium.     See  Pantopon. 

Nerroeidin. — The  same  as  Nervocidin  (q.  v.).  Dumont  ("Allge- 
meine  u.  lok.  Anesthesie,"  1903,  234)  and  others  use  this  name  instead  of 
"Nervocidin,"  etymologically  the  correct  term. 

Nervocidin. — The  hydrochlorid  of  alkaloids  contained  in  the  Indian 
plant  "Gasu-Basu"  (Fharm.  Ztg.,  ^7,  317).  Nervocidin  was  isolated 
by  Dalma,  its  anesthetic  properties  were  discovered  by  a  Hungarian 
dentist  of  Fiume,  and  it  was  studied  by  Fenyvessy  in  the  Institute  of 
Bokay,  Budapest,  pharmacologically.  Nervocidin  is  described  as  a  hy- 
groscopic, yellow  amorphous  powder,  easily  soluble  in  alcohol  and  ether. 
Applications  of  a  0.1  per  cent  solution   are  said  to  produce  complete 


A   LIST    OF    ANESTHETICS  781 

anesthesia  on  mucous  surfaces.  It  has  been  used  in  the  eye  in  doses 
of  2  minims  of  a  0.3  per  cent  solution;  stronger  solutions  are  said  to 
cause  difficulties.  For  the  cornea  a  0.01  per  cent  solution  is  used.  Xer- 
vocidin  is  used  chiefly  in  dentistry  to  anesthetize  painful  pulpa,  in  the 
form  of  the  hydrochlorid,  which  is  very  soluble  in  water.  Hypodermic 
injections  in  animals  produce  paralysis  of  the  motor  centers  and  periph- 
eral nerves,  ending  in  death.  (See  J.  de  V Anesthesie,  1902;  Du- 
mont's  "Allgemeine  u.  lok.  Anaesthesie/'  1903,  231  and  235.) 

Neurocain. — Billets  containing  1/12  grain  (0.005  gm.)  of  cocain 
hydrochlorid  for  use  as  a  local  anesthetic  in  dental  practice  and  in 
pressure  anesthesia.  ISTeurocain  is  said  to  be  composed  entirely  of  co- 
cain hydrochlorid,  without  excipient,  and  to  have  the  advantage  over 
cocain  crystals  that  it  dissolves  "almost  instantly"  on  contact  with 
water ;  the  shape  of  neurocain  is  also  said  to  render  it  peculiarly  suitable 
for  marginal  and  all  other  classes  of  cavities,  but  particularly  for  direct 
introduction  into  the  pulp  chamber.  The  billets  are  about  1/2 0th  of  an 
inch  in  thickness  and  i/gth  of  an  inch  long,  and  weigh  1/12  grain; 
they  are  formed  from  "absolutely  pure"  cocain  hydrochlorid  by  special 
machinery.  "No  foreign  matter  of  any  nature  is  incorporated  with  the 
cocain,  either  to  make  the  particles  adhere  or  to  regulate  the  weight." 

Nirvanin  or  Mrvanine. — This  name  was  given  by  a  German  color 
works  to  a  new  product  of  theirs,  the  hydrochlorid  of  di-ethyl-glycocoll- 
meta-amido-ortho-oxy-benzoic-methyl-ester. 


NH.CO.CHjNCCaHfi), 


HO- 


COOCHs 

The  preparation  was  stated  to  consist  of  colorless  prisms,  fusing  at 
+  185°  C.  and  freely  soluble  in  water.  The  anesthetic  properties  of 
Orthoform  {q.  v.)  suggested  the  desirability  of  transforming  these 
sparingly  soluble  or  sensibly  acid  bodies  into  freely  soluble  and  non- 
irritant  compounds  which  should  be  adapted  for  subcutaneous  injection 
as  well.  Nirvanin  was  said  to  obviate  these  objections,  and  it  was 
stated  by  Einhorn  and  Heinz  {Miincli.  vied.  ^Voc^l.,  1898,  No.  49,  1553) 
that  its  principal  utility  consisted  in  its  power  of  producing  local  anes- 
thesia for  surgical  operations  by  means  of  subcutaneous  injections.  It 
was  said  to  share  with  Orthoform  its  enduring  action,  but  to  be  less 
poisonous  and  at  the  same  time  to  be  antiseptic.  Jouanin  {Bull.  gen. 
de  Therap.,  June,  1898,  906;  Eepert.  de  Pharm.,  1899,  329)  and  Eeynier 


782  ANESTHESIA 

(Rev.  de  Therap.  Med.-chirurg.,  1889,  505)  studied  the  physiological 
action  of  nirvanin.  The  former  regarded  it  as  the  least  toxic  of  all 
bodies  then  employed  for  local  anesthesia,  since  the  lethal  dose  amounted 
to  0.7  gm.  per  kg.  Eeynier  confirmed  the  statements  of  Jouanin,  but  in- 
dicated, at  the  same  time,  that  the  anesthetizing  power  was  visibly  less 
than  that  of  cocain.  On  the  pharmacology  of  Nirvanin,  see  Didrichson: 
Wratscli^  1900,  No.  21.  In  surgical  operations  good  results  were  wit- 
nessed by  Boisseau  (These  de  Bordeaux,  1899)  and  by  Luxenburger 
(Miinch.  med.  Woch.,  1899,  Nos.  1,  2,  and  38),  the  latter  even  going  so 
far  as  to  give  nirvanin  the  preference  over  cocain  and  cocain  mixtures 
in  anesthesia  by  the  infiltration  and  regionary  methods.  Holscher 
(Munch,  med.  Woch.,  1899,  No.  8,  247)  and  Schmidt  (ibid.,  1899, 
No.  38,  1255)  employed  nirvanin  in  regionary  anesthesia  and  noted 
that  its  use  gave  rise  to  violent  pains.  Experiments  on  the  use  of  nir- 
vanin in  dental  surgery  were  made  by  Dumont  and  Legrand:  Rev.  de 
Stomatol.,  March  20  and  June,  1899;  Stubenrauch:  Miinch.  med.  Woch-, 
1899,  No.  38,  1255;  Wittkowski:  Odontol.  Blatter,  1898,  No.  15;  Eoten- 
berger:  Deut.  zahndrztl.  Woch.,  1898,  No.  38;  Fricke,  Schroder,  and 
Carras:  "Correspondenz  f.  Zahndrzte,  1899,  No.  3,  264;  Bounard: 
L'Odontologie,  April  30,  1899,  and  others.  The  first  three  mentioned 
writers  expressed  a  favorable  opinion  on  the  properties  of  nirvanin, 
whereas  the  last  three  joint  authors  condemned  it,  since  its  injection 
was  found  to  invariably  produce,  in  a  more  or  less  pronounced  degree, 
pains  in  the  puncture  canals  and  their  surroundings,  and  to  give  rise 
to  edematic  swellings  liable  to  persist  for  days.  In  1899  it  was  di- 
rected that  regionary  anesthesia  according  to  Oberst  be  effected  by 
means  of  a  2  per  cent  solution  of  nirvanin;  that  0.1  to  0.5  per  cent 
solutions  be  used  in  Schleich's  method  of  infiltration;  and  that  2  to  5 
per  cent  solutions  be  used  in  dental  surgery.  Marcus  (Deut.  zahndrztl. 
Woch.,  1903,  No.  39)  published  some  observations  respecting  the  use  of 
nirvanin  in  dental  surgery,  as  did  Guadagnini  (Bollett.  delle  scienze 
med.,  1903,  77) ;  these  operators  appeared  to  be  favorably  impressed 
with  the  anesthetic.  Ouwarow  (Wratsch,  1900,  No.  23)  found  that 
nirvanin  exercised  an  elective  action  upon  the  sympathetic  nerve,  since 
its  use  occasionally  gave  rise  to  irregular  dilatation  of  the  pupil,  accelera- 
tion of  the  action  of  the  heart,  flow  of  tears,  and  ptyalism, 

Nirvanin  is  no  longer  on  the  market. 

Nitrogen. — While  nitrogen  cannot  be  regarded  as  an  anesthetic, 
producing,  as  it  does,  simple,  uncomplicated  asphyxia,  Sanderson,  Mur- 
ray, and  Turner  (Brit.  Med.  J.,  June  13,  1868)  experimented  with  the 
gas,  finding  that  its  primary  effect  was  to  accelerate  the  movements  of 
respiration  and  circulation;  respiration  was  then  retarded  and  labored, 
while  the  pulse  became  slow  and  irregular.  The  pupils,  which  had 
been  dilated,  now  became  contracted.     The  countenance  was  pallid,  and. 


A   LIST    OF    ANESTHETICS  783 

there  was  no  appearance  of  cyanosis.  Continued  inhalation  caused  a 
renewed  acceleration  of  the  pulse,  accompanied  by  retardation  of  respira- 
tion, and  the  production  of  a  degree  of  insensibility  sufficient  for  the 
painless  extraction  of  a  tooth. 

Nitrous  Oxid.— See  Chapter  IV.  Hunter  (Eng.  Pat.  7,343,  1885) 
proposed  mixing  nitrous  oxid  with  vapor  of  alcoholic  tinctures  of  hops, 
etc. 

Nopain. — This  dental  anesthetic  is  said  to  contain  1  part  cocain 
hydrochlorid ;  I/4  part  phenol;  5  parts  glycerin;  4  parts  adrenalin  solu- 
tion (1 :  1000)  ;  and  4  parts  absolute  alcohol. 

Nor-Cocain. — When  nor-1-ecgonin  has  benzoyl  and  methyl  groups  in- 
troduced, as  in  ordinary  cocain,  nor-cocain,  a  powerful  anesthetic,  is  pro- 
duced. This  is,  however,  too  toxic  for  practical  purposes,  owing,  proba- 
bly, to  the  presence  of  the  imid  group  (NH). 

Novadrin. — A  solution  containing  novocain  (0.015  gm.)  and  adre- 
nalin (0.00005  gm.),  for  subcutaneous  injection. 

Novocain  or  Novocaine  (Mon-hydrochlorid  of  para-amino-benzoyl- 
diethyl-amino-ethanol, 


NH2<^  ^OO.C2H4N(C2H5)2.HCl) . 


This  compound  produces  a  profound  anesthetic  action  subcutaneously ; 
this  passes  ofE  quite  soon,  leaving  no  symptoms  of  irritation.  Le  Brocq 
{Pharm.  J.,  82,  673)  found  that  novocain  is  equal  in  anesthetic  power 
to  cocain,  and  that  its  toxicity  and  destructive  action  are  much  less. 
Experiments  by  Gros  {Arch.  exp.  Path.  Pharm.,  67,  132),  with  the 
borate,  bicarbonate,  secondary  phosphate,  acetate,  and  chlorid  of  novo- 
cain, showed  their  narcotizing  power  to  decrease  in  the  order  given. 

Novocain  crystallizes  from  alcohol  in  colorless  needles  possessing  a 
melting  point  of  +156°  C.  It  can  be  heated  to  +120°  C.  without 
decomposition.  It  dissolves  in  equal  parts  of  cold  water,  and  the  solu- 
tion possesses  a  neutral  reaction  and  may  be  boiled  without  decomposi- 
tion; it  dissolves  in  cold  alcohol  in  the  proportion  of  1:30.  Caustic  alka- 
lies and  alkaline  carbonates  precipitate  the  free  base  from  the  aqueous 
solutions  in  the  form  of  a  colorless  oil  which  soon  solidifies  to  a  crystal- 
line mass;  on  the  other  hand,  sodium  bicarbonate  mixes  with  the  water 
solution  without  producing  a  turbidity.  Alkaloidal  reagents,  as  potas- 
sium-mercuric iodid,  picric  acid,  and  iodo-potassium  iodid  solution,  pro- 
duce precipitates  even  in  very  dilute  water  solutions  of  novocain.  Phar- 
macological investigations  show  that  novocain  possesses  the  same  action 
as  cocain  upon  the  peripheral  sensory  nerves,  and  that  the  0.25  per  cent 
solution  suffices  completely  to  anesthetize  even  the  thick  nerve  trunks, 
as  the  sciatic  nerve,  in  about  ten  minutes.  It  is  said  to  produce  no 
by-effect  when  applied  locally,  and  that  there  are  no  symptoms  of  irri- 


784  ANESTHESIA 

tation  even  when  strong  solutions  are  used.  Experiments  on  animals 
showed,  it  is  reported,  that  no^'ocain  is  about  six  times  less  toxic  than 
cocain,  far  less  toxic  than  any  of  the  cocain  substitutes,  and  the  general 
effect  on  the  system  after  its  absorption  is  scarcely  perceptible,  neither 
the  circulation  nor  the  respiration  being  affected.  Moreover,  that  the 
cardiac  activity  does  not  suffer,  and  that  no  mydriasis  is  produced.  It 
has  been  shown  that  novocain  not  only  does  not  reduce  the  action  of 
suprarenalin,  but  increases  it.  The  indications  are  the  same  as  for 
cocain,  and  it  is  said  to  be  useful  in  cases  in  which  cocain  is  indi- 
cated. 

Dosage. — For  infiltration  anesthesia,  solutions  of  0.25  gm.  (4  grains) 
novocain  in  100  or  50  gm.  (3.2  or  1.6  ounces)  physiologic  salt  solution, 
with  5  or  10  drops  of  e|)inephrin  solution  (1:1000);  for  instillations 
and  injections,  solutions  of  0.1  gm.  (IV2  grains)  novocain  in  10  or  5  gm. 
(150  or  75  grains)  salt  solution,  with  or  without  10  drops  of  epinephrin 
solution  (1:1000).  In  ophthalmology,  1  to  5  to  10  per  cent  solution, 
in  rhinolaryngology,  5  to  20  per  cent  solutions  are  recommended,  with 
the  addition  of  6  to  8  drops  of  epinephrin  solution  (1:1000)  to  each 
10  c.  c.  (160  minims).  Internally,  owing  to  its  feeble  toxicity,  it  may 
be  given  in  doses  up  to  0.5  gm.  (7^^  grains)  to  adults. 

The  literature  relating  to  novocain  is  quite  extensive;  a  number  of 
the  references  follow  in  chronological  order: 

Braun,  H. :    Deut.  med.  Woch.,  1905,  No.  42. 

Biberfeld,  Job. :    Med.  Klinih,  1905,  No.  48. 

Heineke,  H.,  and  Lawen,  A. :    Deut.  Z.  f.  Chir.,  SO,  180. 

Sachse,  B. :    Deut.  zahndrztliche  Woch.,  1905,  No.  45. 

Danielsen,  Wilh. :    Milnch.  med.  Woch.,  1905,  No.  46. 

Schmidt,  Erhardt:    Muncli.  med.  Woch.,  1905,  No.  46. 

Duhot :    Ann.  de  la  polidin.  centrale  de  Bruxelles,  1905,  No.  12. 

Krecke :    Milnch.  med.  Wocli.,  1906,  No.  6,  287. 

Liebl,  Fritz:    Munch,  med.  Woch.,  1906,  No.  5. 

Cisler,  Josef:    Casopis  Lel-.aruv  Geshych  (Prag),  1906,  No.  5. 

Klein:    Les  Nouveaux  Remedes,  1906,  No.  3. 

Sonnenburg,  Ed. :    Von  Leuthold-Gedenlcschrift,  1906,  2. 

Best,  F. :    Med.  Woch.,  1906,  No.  10. 

Lucke,  Eobert:    Monats.  f.  Harnkranhh.  und  Sex.  Tlygiene,  1906,  3. 

Mayer,  Theodor.    Dermatologische  Z.,  1906,  13,  No.  3. 

Hermes,  0. :  Med.  Klinih,  1906,  No.  13. 

Ciezynski,  A. :    Deut.  Monats.  f.  Zahnheilk.,  Apr.,  1906. 

Opitz:    Milnch.  med.  Woch.,  1906,  No.  20. 

Willke,  0. :    Medico,  1906,  No.  19. 

Euler :    Dmt.  zahndrzil.  Woch.,  1906,  No.  20. 

Gebb,  H. :    Archiv  filr  Augenheilk.,  May,  1905,  55,  Nos.  1  and  2. 

Lazarus,  Paul:    Z.  f.  physikal.  und  didtet.  Therap.,  1906,  10,  No.  2. 


A   LIST    OF    ANESTHETICS  785 

Freemann:    Dermatol.  Zentralb.,  190G,  No.  8. 

Brunner:   Munch,  med.  Woch.,  1900,  No.  23. 

Pinet  and  Jeay:    L'Odontologie,  May  30,  1900,  No.  10. 

Fischer,  Guido :    Deut.  Monats.  f.  ZahnheiUc,  June,  190G. 

Graeser,  Carl:  Jahresher.,  1905  and  1906,  d.  Deut.  Kranken.  Nea- 
pel,  42. 

Haug:  "Therap.  von  Ohralfektionen,"  Archiv  f.  Olirenlieilk.,  190G, 
69. 

Misch,  Julius:  Oesterreichisch-Ungarische  Yierteljahres.  f.  Zahn- 
heilk.,  July,  1906,  No.  3. 

Freund,  Eich. :  Deut.  med.  Woch.,  1906,  No.  28 ;  and  Milnch.  med. 
Woch.,  1906,  No.  30. 

Stieda,  A. :    Munch,  med.  Woch.,  1906,  No.  30,  1490. 

Katz,  Leo :    Deut.  med.  Woch.,  1906,  No.  36. 

Hoppe:    Die  drztliche  Praais,  1906,  No.  16. 

Lindenstein:   Deut.  med.  Woch.,  1906,  No.  45. 

Blondel,  Paul:    Eev.  de  Therap.  Med.-chir.,  1906,  Dec.  23. 

Hamecher,  Hans:     Odontol.  Blatter,  11,  Nos.  7-8. 

Hoffmann,  C. :    Miinch.  med.  Woch.,  1906,  No.  52. 

Eemien,  Carl:    Allgem.  med.  C entral-Z eitung ,  1906,  No.  8. 

Eegnier :    Bull,  de  VAcad.  de  Med.,  1907,  484. 

Nast-Kolb:    Miinch.  med.  Woch.,  1908,  No.  13. 

Struthers:    Ednh.  Med.  J.,  Feb.,  1908. 

Bier,  August:  Archiv  f.  hlin.  Chir.,  86,  No.  4;  Surg.  Gynec.  and 
Obstet.,  Nov.,  1908. 

Cramer:    Dissert.,  Freiburg,  1908. 

Stoekel,  W. :    Central,  f.  Gynak.,  1909,  No.  1. 

Albright,  J.  D. :     "Albright's  Office  Pract.,"  July,  1909. 

Hahn:   Deut.  zahndrztl.  Woch.,  1909,  No.  5. 

Nystrom:    Zentralb.  f.  Chir.,  1909,  No.  5. 

Blum :   Z.  f.  Urologie,  1909,  No.  2. 

Bolze:    Zahntechn.  Rundschau,  1909,  No.  9. 

Erhart :    Zahntech.  Rundschau,  1909,  No.  1. 

Prinz :  Zahndrztl.  Rundschau,  1909,  Nos.  4-10 ;  and  Deut.  zahndrztl. 
Zeit.,  1909,  No.  10. 

Sieber:    Miinch.  med.  Woch.,  1909,  No.  10. 

Bier :    Berl.  klin.  Woch.,  1909,  No.  11. 

Le  Brocq:   Brit.  Med.  J.,  1909,  No.  2517,  783. 

Petrow:    Zentralbl.  f.  Chir.,  1909,  No.  14. 

Baarnhielm:    Allmdnna  Svenska  Ldkartidningen,  1909,  No.  11. 

V.  Lichtenberg:    Deut.  med.  Woch.,  1909,  No.  16. 

Busse:    Therap.  der  Gegenwart,  1909,  No.  5. 

Spisharny:    Russkiy  Wratsch,  1909,  No.  9. 

Braun:    Deut.  med.  Woch.,  1909,  No.  16. 


786  ANESTHESIA 

Euprecht:  Monats.  f.  OhrenlieilJc.  unci  Laryngo-Bliinol.,  1909,  Nos. 
3  and  4. 

Braun:   Beitr.  z.  hlin.  Chir.,  1909,  62,  No.  3. 

Diiwawis:   Prakt.  Wratscli,  1909,  No.  11. 

Scheff:    Osterr.-ungar.  Vierieljahressch.  f.  Zalinlieilh.j,  1909,  No.  1. 

Fischer :    Deut.  zahndrztliche  Woch.,  1909,  No.  23. 

Lemire  and  Ducrotoy:  "Eecueil  de  memoires  et  observations  sur 
I'hygiene  et  la  medecine  veterinaires  inilitaires,"  1908,  10. 

Canny  Eyall:    The  Clin.  J.,  1909,  No.  871. 

Hammer:    Deut.  militdrdztliche  Z.,  1909,  No.  11. 

Gros:   Munch,  med.  Woch.,  1910,  No.  39. 

Lawen :   Ihid. 

Krecke:    Milnch.  med.  Woch.,  1910,  No.  26,  2447. 

Gross:    Gyndkol.  Rundschau,  1910,  No.  17. 

Kraatz:    ZentralU.  f.  Gyndkol,  1910,  No.  22. 

Kutscher:    Deut.  m,ed.  Woch.,  1910,  No.  24,  1129. 

Biinte-Moral :    Deut.  Monats.  f.  Zahnheilk.,  1910,  No.  2. 

Senator:   Munch,  med.  Woch.,  1910,  No.  10,  524. 

Schliiter:   Klin.  Monatshl.  Augenheilk.,  Ji-B;  Biochem.  Centr.,  8,  900. 

Moller :    Deut.  zahndrztl.  Woch.,  1910,  No.  35 ;  1911,  No.  16. 

Gros:    Arch.  exp.  Path.  Pharm.,  1912,  67,  132-6. 

Prinz:   Dental  Summary,  Feb.,  1912;  Pharm.  J.,  88,  779. 

Novocain,  Adrenalin,  and  Sodium  Bicarbonate. — Novocain,  adren- 
alin, and  sodium  bicarbonate  solutions  have  been  proposed  for  renal 
operations.  See  Milnch.  med.  Woch.,  1911,  No.  26;  Therap.  Gaz.,  Aug. 
1.5,  1911. 

Novocain  Bicarbonate  Solutions. — Gros  (Milnch.  med.  Woch.,  1910, 
No.  39)  demonstrated  that,  in  animals,  solutions  of  salts  of  cocain, 
novocain,  alypin  and  eucain,  to  which  an  alkali  had  been  added,  showed 
a  considerable  increase  in  their  anesthetic  properties.  In  practice,  sodium, 
bicarbonate  was  recommended  for  this  purpose.  For  local  anesthesia 
Lawen  (ibid.)  tested  this  method  especially  with  novocain.  He  found 
on  using  a  solution  of  novocain,  sodium  chlorid,  and  sodium  bicarbonate 
that  the  resulting  anesthesia  occurred  earlier  than  was  the  case  when 
novocain  solution  was  employed,  while  it  continued  for  a  far  longer 
time.  He  gave  formulas  for  preparing  three  different  strengths  of  solu- 
tions to  be  used  for  sacral,  regional,  and  dental  anesthesias.  It  is  said 
that  for  pure  infiltration  anesthesia  no  special  advantages  are  to  be 
obtained  from  solutions  of  novocain  bicarbonate. 

Novocain  Nitrate  (Novocainse  Nitras). — Novocain  nitrate  is  1-para- 
aminobenzoyl-2-diethylamino-ethane  nitrate  [C6H4NH2C.00;G2H4.N 
(C2H5)2.HN03^  CigHjiOsNg],  the  nitrate  of  p-aminobfinzoyl(iiethyl- 
aminoethanol,  the  base  contained  in  novocain.  Novocain  nitrate  is  bb- 
tained  in  small  colorless  and  odorless  crystals,  soluble  in  water  arid  al- 


A    LIST    OF    ANESTHETICS  787 

cohol.  The  aqueous  solution  is  neutral  in  reaction.  Melting  point, 
+  100°-102''  C.  (212-215°  F.)-  If  0.1  gni.  novocain  nitrate  is  dissolved 
in  1  c.  c.  concentrated  sulphuric  acid  and  a  solution  of  ferrous  sulphate 
is  carefully  floated  above  it,  a  brown  zone  is  formed  at  the  surface  of 
contact  of  the  two  solutions.  One  part  of  novocain  nitrate  dissolved  in 
10  parts  water  and  acidified  with  nitric  acid  should  yield  no  precipitate 
upon  the  addition  of  silver  nitrate  solution. 

Actions  and  Uses. — As  for  novocain,  it  may  be  prescribed  in  com- 
bination with  silver  salts,  with  which  it  forms  no  precipitate. 

Dosage. — Used  in  3  per  cent  solutions. 

Novocain-Suprarenin  Solutions. 

0 . 5  per  cent  solution  =  Tablet  A  in  2.5  c.  c.  water. 
2.0    "       "  "       =       "      B   "     5  "         " 

K    rj      a  it  it  _  II  /~i    u       1     (I  a 

10.0    "       "  "       =       "      D  "     2  "         " 

2.0    "      "  "       =       "      E  "     1  "         " 

Novocain-Suprarenin  Tablets. — A. — 0.125  gm.  novocain  -j-  0.00016 
gm.  suprarenin  borate,  for  infiltration  anesthesia;  B. — 0.1  gm.  novocain 
-\-  0.00045  gm.  suprarenin  borate;  C. — 0.05  gm.  novocain  -\-  0.000108 
gm.  suprarenin  borate,  for  medullary  anesthesia;  D. — 0.2  gm.  novocain 
-\-  0.00015  gm.  suprarenin  borate  -|-  0.09  gm.  sodium  chlorid,  for  dental 
operations;  E. — 0.02  gm.  novocain  +  0.000015  gm.  suprarenin  borate 
-(-  0.009  gm.  sodium  chlorid,  for  dental  operations. 

Novoconephriii. — jSTovocain,  0.018  gm.;  paranephrin,  0.00007  gm. ; 
with  a  trace  of  thymol,  in  physiological  salt  solution,  1.25  gm.  An  in- 
jection-anesthetic in  dentistry. 

Novo-Dentaesthin. — This  dental  local  anesthetic  contains  in  1  c.  c.  of 
a  physiological  salt  solution  0.01  gm.  beta-eucain  lactate,  0.015  gm.  novo- 
cain, and  0.05  gm.  of  synthetic  suprarenin. 

Novorenal. — The  0.25  per  cent  solution  contains  0.0125  gm.  of  novo- 
cain, 5  gm.  of  physiological  salt  solution  (NaCl),  and  0.00001625  gm. 
suprarenin  hydrochlorid ;  the  0.5  per  cent  solution  contains  double  the 
above  quantities  of  novocain  and  suprarenin;  the  1  per  cent  solution 
contains  0.01  gm.  novocain,  1  gm.  of  physiological  salt  solution,  and 
0.00009  gm.  of  adrenalin  hydrochlorid ;  the  2  per  cent  solution  contains 
0.02  gm.  of  novocain,  1  gm.  of  physiological  salt  solution,  and  0.00009 
gm.  of  suprarenin  hydrochlorid.  These  solutions  are  employed  as  local 
anesthetics;  novorenal  2  per  cent  is  most  used  by  dentists,  and  the  ex- 
periences are  reported  to  be  very  good. 

Novorobiol. — See  Rohiol. 

Nussbaum's  Mixture. — Alcohol,  1  part;  chloroform,  1  part;  and 
ether,  3  parts.  Mixed.  See  Potter:  "Mat.  Med.  Pharm.  Therap.,"  10th 
ed.,  88. 


788  ANESTHESIA 

Obalgo. — A  dental  local  anesthetic  of  unknown  origin. 

Obtundo. — A  dental  local  anesthetic  consisting  of  chloretone,  cocain, 
nitroglycerin,  thymol,  menthol,  and  oils  of  wintergreen,  eucalyptus,  and 
cloves. 

Octane. — This  hydrocarbon,  which  is  contained  in  commercial 
ligroine  in  crude  petroleum,  produces  an  anesthesia  similar  to  that  caused 
by  Hexane  (q.  v.)  ;  in  addition,  according  to  Versmann,  there  is  a  tend- 
ency to  vomiting.  The  unsaturated  hydrocarbons  ethylene,  propylene, 
and  butylene  are  said  to  have  a  very  similar  action. 

Odiot. — Tincture  of  benzoin,  with  balsam  of  Peru  and  oil  of  cloves. 
Used  in  odontalgia. 

Oil  Absinthium,  or  Oil  Wormwood. — This  oil  possesses  anesthetic 
properties. 

Omnopon. — See  Pantopon. 

O-phthaloyl-bis-methylecgonin. — Einhorn  and  Klein  (Ber.,  1888, 
21,  3335)  have  shown  that  this  compound  possesses  a  physiological  action 
similar  to  that  of  cocain. 

Opiopon. — According  to  Flury  {Z.  angew.  Chem.,  26,  242),  this 
preparation  contains  the  alkaloids  of  opium.     See  Pantopon. 

Opon. — According  to  Flury  {Z.  angew.  Chem.,  26,  242),  Opon  is  a 
morphin-free  Pantopon  (q.  v.). 

Orthoform     (Orthoform-Proper;    Para-amido-meta-oxybenzoic    acid 

methyl  ester,  HjN<(^  ^COOCH,).  See  Ortho form-New,  which  is 

a  finer,  whiter,  more  homogeneous  powder  and  is  less  expensive  than 
orthoform-proper.  Like  orthoform-new,  orthoform-proper  exercises 
its  full  local  anesthetic  action  even  in  a  10  to  20  per  cent  mixture 
with  amylum  or  talcum.  It  is  very  slightly  soluble  and  is  also  but 
feebly  toxic.  It  is  said,  however,  that  it  is  only  active  when  directly 
applied  to  the  nerve  endings,  and  that  it  is  useless  when  applied  to  the 
unbroken  skin  or  mucous  membranes.  The  soluble  hydrochlorid  of 
orthoform-proper  is  not  used  in  practice,  owing  to  the  fact  that  its 
injection  produces  pain.  According  to  Francis  and  Fortescue-Brick- 
dale  ("The  Chemical  Basis  of  Pharmacology,"  1908,  310),  orthoform 
has  also  been  observed  to  produce  severe  dermatitis  of  an  erythematous, 
pustular,  or  even  gangrenous  type. 

Orthoform-New  ( Meta-amido-para-oxybenzoate  of  methyl). — Ortho- 
form-New  is  methyl  meta-amino-para-oxybenzoate, 

C«H3.NH,.0H.C00(CH3),  3  :  4 :  1  =  CgHAN, 
the  meta-amino-para-oxybenzoic  acid  ester  of  methyl  alcohol.     It  is  pre- 
pared by  the  nitration  of  para-oxybenzoate  of  methyl  and  reduction  of 
the  nitro  product  obtained.     A  large  number  of  bodies  have  been  pre- 


A  LIST   OF   ANESTHETICS  789 

pared  which  resemble  orthoform,  but  only  a  few  are  of  any  practical 
use.  It  is  obtained  in  a  fine,  white,  crystalline  powder,  neutral  in  reac- 
tion, and  melting  at  +  141°  to  143°  C.  (285.8°  to  289.4°  F.),  odor- 
less and  tasteless.  It  is  scarcely  soluble  in  water,  but  is  soluble  in  5 
or  (5  parts  of  alcohol  and  50  parts  of  ether.  It  is  decomposed  by  boiling 
with  water,  or  by  warming  with  alkalies  or  their  carbonates,  into  methyl 
alcohol  and  paroxybenzoic  acid.  When  crystallized  from  chloroform  it 
sometimes  assumes  the  form  of  white  crystals  melting  at  -|-  110°  to 
111°  C.  (330°  to  231.8°  F.),  returning,  on  melting,  to  the  ordinary 
form.  The  filtrate  obtained  after  shaking  a  small  portion  with  water 
produces  a  fugitive  color  with  ferric  chlorid,  and  should  not  give  a 
reaction  with  silver  nitrate.  A  solution  of  0.1  gm.  in  2  c.  c.  of  water  by 
the  aid  of  hydrochloric  acid  is  colored  yellowish  red  on  addition  of 
sodium  nitrate,  and  then  deposits  a  yellow  precipitate,  deepening  to  red 
on  exposure  to  the  air. 

It  is  decomposed  by  heating  with  water;  it  is  incompatible  with  al- 
kalies and  their  carbonates.  Orthoform  is  also  incompatible  with  silver 
nitrate  (see  Bock:  Therap.  Monatsh.,  1898,  413),  the  organic  silver 
albuminoid  preparations,  formaldehyd,  potassium  permanganate,  ferric 
chlorid,  antipyrin,  and  bismuth  subnitrate.  It  may,  however,  be  com- 
bined with  solutions  of  mercuric  chlorid,  tincture  of  iodin,  turpentine, 
solutions  of  copper  sulphate,  iodoform,  dermatol,  zinc  oxid,  europhen, 
aristol,  calomel,  and  salicylic  acid.  It  is  also  applicable  in  3  to  5  per 
cent  solutions  of  phenol,  and  with  lysol  and  cresol  solutions.  Its  hydro- 
chlorid  is  soluble,  but  irritant. 

Actions  and  Uses. — Orthoform-New  is  a  local  anesthetic,  resembling 
cocain  in  its  local  action,  but  not  penetrating  the  tissues  on  account  of 
its  insolubility.  It  has  practically  no  action  on  the  unbroken  skin,  except 
for  a  slight  irritation  which  it  produces  about  the  place  of  appli- 
cation. It  is  somewhat  antiseptic  and  practically  non-toxic  in  the  usual 
doses.  It  is  used  internally  to  relieve  the  pain  of  gastric  ulcer.  Since  it 
acts  only  on  ulcerated  surfaces,  the  relief  of  pain  has  been  assumed  to 
be  evidence  of  the  existence  of  an  open  ulcer.  It  has  been  applied  lo- 
cally as  an  analgesic  to  wounds  of  every  description.  It  has  been  used 
in  dentistry,  in  nasal  catarrh,  hay  fever,  etc. 

Orthoform  paralyzes,  just  as  cocain,  all  the  peripheral  sensory  nerve 
endings  and  nerve  trunks  with  which  it  is  brought  into  direct  contact. 
Therefore,  because  of  its  insolubility,  it  can  only  exercise  its  properties 
when  applied  to  wound  surfaces  where  the  nerve  endings  are  exposed, 
and  does  not  penetrate  the  tissues.  Its  antiseptic  action  is  weak.  Heinz 
determined  experimentally,  and  this  point  has  been  confirmed  by  clini- 
cal work,  that  the  drug  exerted  practically  no  toxic  action  on  the  econ- 
omy at  large  when  administered  in  the  doses  recommended.  Cf.  Soulier 
and  Guinard :    Repert.  de  Fharm.,  1898,  420.     Owing  to  the  slow  solu- 


790  ANESTHESIA 

bility  of  orthoform,  only  small  quantities  are  absorbed  at  a  time,  thus 
prolonging  anesthesia  for  hours  or  days.  It  is  said  to  be  applicable 
whenever  pain  is  in  evidence,  and  to  be  of  value  as  a  sprinkling  powder, 
pure  or  mixed  with  some  bland  powder,  in  solution  in  alcohol,  ethyl 
ether,  or  collodion,  and  in  an  ointment. 

Dosage. — Internally,  0.5  to  1  gm.  (8  to  15  grains)  in  emulsion;  lo- 
cally, in  substance  as  a  dusting  powder  or  mixed  with  milk  sugar  for 
insufflation,  dissolved  in  ether  and  mixed  with  oil  for  penciliugs,  or  as 
a  salve  with  wool  fat,  etc. 

The  following  are  some  of  the  references  to  the  literature  of  ortho- 
form. 

Einhorn  and  Heinz :  "Orthoform ;  ein  Lokalanasthetikum  f iir 
Wundschmerz,   Brandwunden,   Geschwiire   usw.,"  Milnch.   med.    ^Vocli., 

1897,  No.  34;  No.  37,  555.  ■ 

Neumayer:  tJber  Orthoform,"  Miincli.  med.  Woch.,  1897,  No.  44, 
1230. 

Klaussner:  "tJber  Orthoform,"  Miinch.  med.  Woch.,  1897,  No.  46, 
1289. 

Boisseau:  "De  I'orthof orme ;  son  emploi  en  oculistique,"  Gaz.  liehd. 
d.  Sciences  med.  d.  Bordeaux,  1897,  G03-607. 

Kallenberger :  "tJber  Orthoform,"  Inaug. -Dissert.  Miinchen, 
1897. 

Lichwitz  and  Sabrazes:  "L'Orthoforme  comme  anesthesique  et 
comme  antiseptique,"  Bull,  med.,  Nov.,  1897,  No.  94. 

Tschernogoubov :  "Orthoforme  pour  injections  souscutanees,"  Sem. 
med.,  1897,  No.  16. 

Hirschbruch:     "Orthoform,"  Berl.  Uin.  \Yocli.,  1897,  No.  51. 

Boisseu:  "L'Orthoforme  en  laryngologie  et  en  stomatologic,"  Gaz. 
Jiebd.  d.  Sciences  med.  d.  Bordeaux,  Jan.,  1898,  39-41;  also,  Presse 
med.,  1898,  89. 

Yonge:  "Treatment  of  Painful  Ulcerations,"  Brit.  Med.  J.,  Feb., 
1898;  see,  also,  Canadian  J.  Med.,  1898,  No.  3. 

Cumston:     Boston  Med.  and  Surg.  J.,  Mar.  24,  1898. 

Kindler:     "Orthoform,"  Fortsch.  d.  Med.,  Apr.,  1898,  No.  7. 

Bernould  and  Garrel:    "L'Orthoforme  en  laryngologie,"  Lyon  med., 

1898,  No.  13. 

Kallenberger:  "tJber  Orthoform,"  Berl.  Min.  Woch.,  1898,  No.  12; 
I naug. -Dissert.,  Miinchen,  1898. 

Dreyfuss:  "Kombination  von  Infiltrationsanasthesie  nnd  Ortho- 
form,"  Munch,  med.  Woch.,  1898,  No.  17. 

Nogoues:  "L'Orthoforme  dans  les  affections  douloureuses  de  la 
vessie,"  Annales  des  maladies  des  organes  genito-urinaires,  Paris,  1898, 
547. 


A   LIST    OF    ANESTHETICS  791 

Fromaget:  "Orthoform  bei  Augenaffektionen,"  Berl.  Iclin.  Woch., 
1898,  No.  9. 

Ginestoux:  "Acide  arsenieux  et  orthoforme  dans  le  traitement  du 
cancer  epithelial,"  Sem.  med.,  Apr.,  1898,  No.  20. 

Cerry  and  Tourecek:  "Emploi  de  I'orthoforme,"  Sem.  med.,  Apr. 
13,  1898. 

Bonnard:  "L'Orthoforme  et  le  chlorhydrate  d'Orthoforme  en  art 
dentaire,"  L'Odontologie,  May  30  and  June  15,  1898. 

Brocq:  "Accidents  produits  par  I'orthoforme,'  Sem.  med.,  1898, 
No.  17. 

Bornstein:  "Orthoform,"  Zahndrzt.  Bunds.,  May  15,  1898,  No. 
306. 

Lichtwitz:  "Traitement  de  la  rhinite  vaso-motrice  (hydrorrhee 
nasale,  fievre  des  foins)  par  I'orthoforme,"  Le  Bull,  med.,  1898,  No.  7; 
Arch,  interuat.  Laryngol.,  1898,  No.  1. 

Loeb:  "Orthoform  als  Anasthetiknm  bei  intramuskularen  Injek- 
tionen,"  Monats.  f.  praJct.  Dermatol.,  Jan.  27,  1898.  . 

Jessen :    "Orthoform,"  Deut.  zahndrzt.  Woch.,  1898,  No.  10. 

Blondel:  "L'Orthoforme  en  gynecologic,"  Rev.  d.  Therap.,  May, 
1898,  No.  10. 

Manquat:  "Deux  nouveaux  anesthesiques  locaux,  I'orthoforme  et  la 
nirvanine,"  Bull,  med.,  1898,  984. 

Pozzi:  "L'Orthoforme  en  gynecologic,"  Le  Scalpel,  May,  1898,  No. 
46. 

Mosse:  "Verhalten  des  Orthoforms  im  Organismus,"  Deut.  med. 
Woch.,  1898,  No.  26;  see,  also,  Klin.-Therap.  Woch.,  1898,  No.  25. 

Mosse,  Herzfeld,  Jastrowitz,  v.  Leyden,  Goldscheider,  Frankel, 
Ehrlich :  Discussion :  "Verhalten  des  Orthoforms  in  Organismus," 
Allge.  med.  Central-Zeit.,  June,  1898,  No.  47;  Deut.  med.  Woch.,  1898, 
No.  17. 

Bezold:    "Orthoform,"  Miinch.  med.  Woch.,  1898,  No.  26. 

Gianelli :  "L'Orthoformio  in  ginecologia,"  Archiv.  Ital.  di  Ginecol., 
1898,  508-511. 

Schech:    "Orthoform,"  Miinch.  med.  Woch.,  1898,  No.  26. 

Fink:  "Orthoform  in  der  Ehino-Laryngologie,"  Arztl.  Praxis, 
1898,  No.  20. 

Jessen:  "Orthoform,"  Jahresbericht  der  Poliklinik  fiir  Zahnkrank- 
heiten,  Strassburg,  1898-1899 ;  Deut.  zahndrztl.  Woch.,  1898,  No.  10. 

Ivorn:  "Orthoform  bei  Prurigo  und  bei  Herpes  Zoster,"  Die  drztl. 
Praxis,  July,  1898,  No.  13. 

Hecker:    "tJber  Orthoform,"  Inaug. -Dissert.,  Berlin,  July,  1898. 

Bock:  "Beitrage  zur  Kenntnis  des  Orthoforms,"  Therap.  Monatsh., 
1898,  413. 


792  ANESTHESIA 

Eotenberger:  "Orthoform  und  'Orthoform  neu'  und  Nirvain/' 
Deut.  zahndrz.  Woch.,  1898,  No.  38. 

Klaussner :  "Uber  Orthoform  und  'Orthoform  neu,'  "  Munch,  nied. 
Woch.,  1898,  Xo.  42,  1338. 

Kassel:  Uber  Orthoformemulsion,"  Therap.  Monatsh.,  Oct.,  1898, 
556. 

Heinzel :    "Uber  Orthoform,"  Wiener  Min.  Woch.,  1898,  No.  48. 

Wohlgemuth:    "Uber  Orthoform,"  Deut.  med.  Woch.,  1898,  No.  44. 

Hanszel:     "Orthoform,"  Wiener  Min.  Woch.,  1898,  No.  49. 

North :  "Orthoform  as  a  Local  Anesthetic,  Analgesic,  and  Antisep- 
tic," Am.  Med.  Compend.,  Nov.,  1898, 

Maygrier  and  Blondel:  "Zur  Behandlung  der  Ehagaden  der  Brust- 
warze  bei  stillenden  Frauen,"  Revue  de  Therap.,  1898,  797. 

Apfelstadt :     "Orthoform,"  Deut.  zahndrzt.  Woch.,  1898,  No.  40. 

Hildebrandt:  "Beitrag  zur  Orthoformanasthesie,"  Deut.  med. 
Woch.,  1898,  No.  48;  Therap.  Beil.,  No.  12,  95. 

Lobisch :    "Orthoform,"  Enzyhlopddische  Jahrh.,  1898,  viii. 

Lipowski:     "Larynxerkrankungen,"  Therap.  Monats.,  18,  No.  12. 

Deniges :  "Sur  les  orthoformes,  caracteres  et  differences,"  Bull.  d.  la 
Soc.  d.  Pharmacol,  d.  Bordeaux,  Dec,  1898. 

Ducray:  "L'Orthoforme  et  ses  indications  en  laryngologie,"  Inaug.- 
Dissert.,  Lyon,  1898. 

Herzfeld :  "Verhalten  des  Orthoforms  im  Organismus,"  Allge.  med. 
Centr.-Ztg.,  June,  1898,  No.  47. 

Teisseire :  "Traitement  des  gergures  et  crevasses  du  sein  par  d'ortho- 
forme,"  Inaugural-Dissertation,  Paris,  1898;  also,  Sem,.  med.,  1898,  No. 
57,  226. 

Kionka :  "Uber  neuere  Arzneimitte,"  Therap.  der  Gegenwart,  1899, 
No.  1. 

Holmes:  "The  Use  of  Orthoform  in  Surgery,"  Woman's  Med.  J., 
Jan.,  1899,  No.  1. 

Johnson :    "Orthoform,"  Woman's  Med.  J.,  1899,  No.  1. 

Maygrier:  "Treatment  of  Fissures  of  the  Nipples,"  Med.  Press, 
Jan.  25,  1899. 

Danlos:  "Orthoform,"  La  Presse  med.,  Jan.  14,  1899;  "Injections 
de  calomel  additionees  d'orthoforme  a  titre  d'analgesique,"  J.  d.  Malad. 
Cutan.  et  Syphilit.,  1899,  00. 

Epstein :  "Uber  Orthoform,  bezw.  'Orthoform  neu'  als  Zusatz  zu 
Quecksilberparaffin-Emulsionen,"  Dermat.  Centralhlatt,  February,  1899, 
No.  5. 

Goppert :  "Orthoform,"  Fortsch.  der.  Med.,  1899,  No.  35 ;  "Ortho- 
form,"  Jahrhuch  f.  Kinderheilk.,  N.  F.,  Feb.,  1899,  No.  49. 

Asam:  "Erfahrungen  mit  Orthoform,"  Miinch.  med.  Woch.,  1899, 
No.  8,  252. 


A    LIST    OF    ANESTHETICS  793 

Cheatham:  "A  Note  on  Orthoform,"  Amer.  Therap.,  Feb.,  1899, 
No.  8. 

Mailland:  ''Accidents  provoques  par  I'orthoforme  employe  comme 
topique  des  plaies,"  Province  med.,  1899,  135. 

Meyer:    Laryngologist,  March,  1899. 

Sims:     "Experience  with  Orthoform,"  Therap.  Prog.,  1899,  No.  3. 

Dickenson:  "Orthoform  in  Rectal  Affections,"  Therap.  Prog.,  1899, 
No.  3. 

Crisand:  "Clinical  Note  on  Orthoform,"  Therap.  Progress,  1899, 
No.  3. 

V.  Zander:  "Das  Orthoform  in  der  Laryngologie,"  Gharite-Ann., 
March,  1899,  23. 

Freudenthal:  "Behandlung  des  Hustens  und  der  Tuberkulose," 
Monat.  f.  Ohren-,  Kehllcopf-,  Nasen-  und  Rachenlcrankheiten,  1899, 
No.  3. 

Schroppe:  "Orthoform-Exanthem,"  Petersburger  med.  Woch., 
Mar.,  1899,  No.  12;  No.  13,  100. 

Kindler:  "Weitere  Mitteilungen  iiber  den  Gebrauch  von  Ortho- 
form,"  Fortsch.  der  Med.,  1899,  No.  7. 

Miodowski:     "Orthoform,"  Milnch.  med.  Woch.,  1899,  No.  12,  382. 

Boisseau:  "Contribution  a  I'etude  de  I'orthoforme,"  Inaug. -Dissert., 
Bordeaux,  Mar.  24,  1899. 

Albertin:  "Intoxication  par  I'orthoforme  employe  comme  topique 
dans  le  pansement  des  plaies,"  Lyon  med..  May,  1899. 

Darier:  "De  Taction  analgesiante  de  I'orthoforme  dans  certaines 
affections  oculaires,"  La  Cliniq.  Ophthal.,  Apr.,  1899,  No.  8. 

Brocq:  "De  I'orthoforme  en  dermatologie,"  J.  d.  Pratic,  1899; 
Presse  med.,  1899,  No.  30 ;  "Intolerance  par  I'orthoforme,"  Soc.  frang.  d. 
Dermatol.,  Paris,  Apr.,  1899. 

Dauchez :    "Progres.  med..  May  20,  1899. 

Brocq  and  Besnier :  "firuptions  orthoformiques,"  Soc.  frang  d. 
Dermatol.,  Paris,  April,  1899. 

Brocq  and  Thibierge:    Gaz.  hebd.  de  Med.  et  de  Ghir.,  1899,  No.  32. 

Deniges :  "Priifung  des  Orthoforms,"  Les  Nouveaux  Eemedes,  1899, 
400. 

Wunderlich:  "Zur  Anwendung  von  Orthoform,"  Milnch.  med. 
Woch.,  1899,  No.  40,  1296. 

Gomberz:  "tJber  Versuche  mit  einigen  neuren  Mitteln,"  Monat.  f. 
Ohrenheil,  1899,  No.  6,  256. 

Kassel:     'Orthoform-Neu,"  Monat.  f.  Ohrenheil.,  1899,  No.  6. 

Dunogier:     "L'Orthoforme,"  J.  de  Med.,  June,  1899. 

Soulier  and  Guinard :  "Contribution  a  I'etude  pharmacodynamique 
de  I'orthoforme,"  Archiv.  Jnternat.  d.  Pharmaco.  et  d.  Therap.,  1899,  6. 

Bleuler:     "Orthoform,"  Neurolog.  Gentral,  1899,  No.  14. 


794  ANESTHESIA 

Wright:  "The  Prevention  of  Hayfever/'  N.  Y.  Med.  J.,  May  6, 
1899. 

Ott:    "Orthoform,"  Med.  Arena,  Sept.,  1899. 

Madden:  "Observation  on  Uterus  Cancer  Treatment,"  Dublin  J. 
Med.  8ci.,  1899,  409. 

Maire:  "Behandlung  der  Papilla  fissurata,"  Zentralh.  f.  Gynakol., 
Aug.,  1899,  No.  32. 

Salzer:  "Orthoform  bei  Augenaffektionen,"  Die  ophthal.  Klinih, 
Sept.,  1899,  257. 

Stubenrauch,  Klaussner,  Gossmann,  Krecke,  Moritz:  "Diskussion 
iiber  Orthoform";  Auszug:  Miinch.  med.  Woch.,  1899,  Nos.  38,  39, 
Seite  1254. 

Whien :  "Des  eruptions  dues  a  I'orthoforme,"  Bull.  d.  VHopital 
frang.  d.  Tunis,  1899,  243. 

Mirabeau:  "Orthoform,"  Zentralbl.  f.  Gynakol,  1899,  No.  11; 
Monat.  f.  Gehurts.,  1899,  9. 

Decker :  "Dermatitis  Following  the  Use  of  Orthoform,"  N.  J.  Med. 
J.,  1899,  780. 

Sauer :  "Orthoform-Idiosynkrasie  ?"  N.  Y.  Med.  Monat.,  1899,  No. 
12. 

Bardet:  "Note  sur  les  modes  d'administration  de  I'orthoforme  et 
sur  quelques  applications,"  Bull.  gen.  d.  Therap.,  Feb.,  1900,  262. 

Blondel :  "Traitement  des  crevasses  du  mamelon  par  I'orthoforme,'^ 
Soc.  d.  Therap.,  Feb.,  1900. 

Dejace:    "Orthoforme,"  Le  Scalpel,  July,  1900,  No.  5. 

Luxenburger:  "Experimentelles  und  Klinisches  iiber  Orthoform," 
Miinch.  med.  Woch.,  1900,  Nos.  2,  3,  48,  and  82. 

Sprague :    "Orthoform  Facts,"  Am.  Therap.,  Sept.,  1900,  No.  3. 

Thelberg :  "Treatment  of  Anal  Chancroids,"  N.  Y.  Med.  J.,  May  26, 
1900. 

Norbury :  "Orthoform  in  the  Treatment  of  Epithelioma,"  Med.  Fort- 
nightly, March  26,  1900. 

Helouin:  "L' Orthoforme,"  Bull,  des  Sci.  pharmacol.,  Nov.,  1900, 
No.  11. 

Gleason:    Internat.  Med.  Mag.,  Oct.,  1900. 

Friedlander:  "Orthoformvergiftung,"  Therap.  Monat.,  Dec,  1900, 
No.  12,  676. 

Euhemann:  "Ein  Fall  von  Orthoformvergiftung,"  Therap.  Monat., 
Dec,  1900-1901,  No.  12. 

Lang:  "Erfahrungen  mit  Orthoform  und  Nirvanin,"  Zahndrzt. 
Rundschau,  1900,  6359-6360. 

Plique :     "L' Orthoforme,"  La  Presse  med.,  1900,  204-205. 

Vacek:  "Sur  I'orthoforme,"  Casopis  Laharuv.  CesJcych,  Prag,  1900, 
154. 


A   LIST    OF   ANESTHETICS  795 

Villa:  "Contribution  a  I'etude  experimentale  et  dinique  de  I'ortho- 
forme,"'  Inaugural-Dissertation,  Lyon,  1900. 

Villa:  "A  propos  des  accddents  produits  par  Forthoforme,"  Echo 
med.  de  Lyon,  1900,  161-171. 

Vogt:  "Traitement  de  la  periode  eruptive  du  zona  par  les  applica- 
tions d'orthoformc,"  Bull.  gen.  d.  therap.,  1900,  576. 

Garnault:  "Traitement  de  la  tuberculose  par  la  viande  crue  et  par 
les  injections  intratracheales  d'orthoforme,"  Bull.  d.  la  Soc.  d.  Therap., 
Jan.,  1901. 

Heineck:  "Newer  Local  Anesthetics.  Holocain,  JSTirvanin,  Ortho- 
form,"  The  Bacillus,  Jan.,  1901. 

Brewster:  "A  Eeview  of  Some  of  the  Modern  Medicinal  Prepara- 
tions Used  in  Dentistry,"  Items  of  Interest,  Jan.,  1901,  No.  1. 

Spiess :  "Ein  neuer  Gesichtspunkt  in  der  Behandlung  des  Keuch- 
hustens,"  Miinch.  med.  Woch.,  Apr.,  1901,  No.  15,  596. 

Spiess:  "Ein  neuer  Gesichtspunkt  in  der  Behandlung  des  frischen 
SchnupfenSj"  Archiv  f.  Laryngol.,  1901,  12,  No.  1. 

Colleville :  "Sur  un  cas  de  nevralgie  sacro-lombaire  traite  par  des 
injections  epidurales  de  guaiacol  orthoforme,"  Union  med.  du  Nord-est, 
May  30,  1901. 

Graul:  "tjber  Nebenwirkungen  des  Orthoforms,"  Deut.  med. 
Woch.,  1901,  No.  24,  390. 

Friedrich:  "Sammelreferat  iiber  neuere  Arbeiten  aus  dem  Gebiete 
der  Nasen  und  Kehlkopfkrankheiten,"  Fortsch.  der  Med.,  Sept.,  1901, 
No.  25. 

Siebourg:  "Beitrag  zur  Behandlung  des  Pruritus  vulvae,"  Zentralhl. 
f.  GyndJcol,  1901,  No.  26. 

Hornberger:  "tJber  Orthoform,"  Therap.  Monats.,  October,  1901, 
519. 

Boennecken:    Prager  med.  Woch.,  1901,  No.  37. 

Memmi:  "L'Orthoformio  per  la  diagnosi  dell'ulcera  gastrica," 
Riforma  med.,  17,  Nos.  112-116. 

Dubreuilh :  "Des  Eruptions  orthoformiques,"  La  Presse  med..  May 
18,  1901,  No.  40. 

Holger-Mygind :  "Lehrbuch  der  Krankheiten  der  oberen  Luf twege," 
1901. 

Bouveyron-Siraud :  "Orthoform  innerlich."  Sem.  med.,  1901,  No. 
50,  400. 

Horn:  "Ein  Fall  von  mit  Menthol-Orthoform-Emulsion  behandel- 
tem  Pharynx,"  N.  Y.  Med.  Monat.,  1901,  134. 

Solis-Cohen:  "Orthoform  Lozenges  to  Mitigate  Odynophagia,"  Am. 
Med.,  Nov.  9,  1901. 

Odenthal:  "Schadliehe  Wirkung  des  Orthoforms,"  Deut.  zahndrzt. 
Woch.,  1901,  1623. 


79a  ANESTHESIA 

Heryng:  "Zur  Anwedung  des  Orthoforms,'^  Gazeta  Lekarska,  1901, 
^0.  39. 

V.  Tovolgyi :  "Uber  di  Behandluiig  der  Kehlkopftuberkulose,  mit 
Eiicksicht  auf  die  neuren  Heilmittel/'  Tlierap.  der  Gegenwart,  Mar., 
1902. 

Melenowski :  "Ein  Fall  von  Orthoformvergiftung,"  Gazeta  LeTcarsJca, 
1901,  No.  48. 

Eriedliiuder:  "Eiitgegnuiig  auf  den  Artikel  von  Homberger," 
TTierap.  Monat.,  Nov.,  1901. 

Haug:  "Orthoform  gegen  die  Schmerzen  bei  Furunkeln  des  Meatus 
auditorius,"  Monats.  f.  Ohrenheillc,  1901,  No.  12. 

Homberger:  'SSchlussbemerkung  liber  Orthoform,"  Tlierap.  Monats., 
Feb.,  1902. 

Wright:    Med.  Neivs,  Jan.  19,  1902. 

Bowen:  "Orthoform  Eruptions,"  Boston  Med.  and  Surg.  J.,  Mar. 
20,  1902. 

Spiess;  "Die  Heilwirkung  der  Anasthetika,''  Zentralhl.  f.  innere 
Med.,  Mar.,  1902,  No.  9. 

Veis:  "Ein  Beitrag  zum  Verlaufe  von  Larynxtuberkulose  in  der 
Graviditat,"  Monat.  f.  Ohrenheillc.,  1902,  No.  4. 

Freytag:  "tJber  Kehlkopftuberkulose,"  Munch,  med.  Wocli.,  1902, 
No.  19. 

Wassermann :  "tJber  Nebenwirkungen  des  Orthoforms  und  ihre 
bisher  ungelkliirte  Atiologie,"  Von  Leyden-Festschrift,  1902,  2,  317. 

Dalche :  "Les  leucorrhees  virginales  et  leur  traitement,"  Gaz.  med. 
Beige,  1902,  No.  41. 

Czaplicki :     "Orthoform,"  Przeglad  Lelcarshl,  Ivraku,  1902,  305-30G. 

Gardner  and  Wilson:  "Clinical  Eeport  of  Some  Genito-Urinary 
Cases,"  Buffalo  Med.  J.,  July,  1902. 

Schalenkamp:  "Zur  Frage  der  schadliclien  Nebenwirkungen  des 
Orthoforms,"  Beichs-Med.-Anzeiger,  1902,  No.  16. 

Murdoch :  "Orthoform  in  the  Diagnosis  of  Gastric  Ulcer,"  iV.  Y. 
Med.  J.,  Nov.  29,  1902,  No.  22. 

Plesch:     "A  Tiidovesz  es  Tlineti  Kezelese,"  Budapest,  1902,  41. 

Aveline :  "Contribution  a  I'etude  de  I'orthoforme,"  Monograph, 
Paris,  1902 ;  also,  Gaz.  des  Hop.,  1903,  20. 

Iiobertson:    /.  Am.  Med.  Assn.,  Jan.  17,  1903. 

Luntz :  "Zur  Bchandlung  der  Fissuren  des  Anus,"  St.  Petershurger 
med.  Gesells.  (Arztl.  Bunds.,  1903,  No.  25). 

Dumont:  "Handbuch  der  allgemeinen  und  lokalen  Anasthesie," 
Berlin  and  Wien,  1903,  230. 

Dickinson:    Detroit  Med.  J.,  Aug.,  1903. 

Cohn:  "Tuberculosis  of  the  Larynx/'  Occidental  Med.  Times,  Sept., 
1903. 


A   LIST    OF    ANESTHETICS  797 

Mayer  und  Thiesen:  "Discussion  of  a  paper,  "The  Early  Appear- 
ances, Diagnosis,  and  Treatment  of  Tuberculosis  of  the  Uppei  Air  Pas- 
sages," by  Chappell.    J.  Am.  Med.  Assn.,  Feb.  21,  1903. 

Allen:  "The  Treatment  of  Cancer  by  Caustic  Taste,"  N.  Y.  Med. 
Record,  Dec.  13,  1903. 

Teissier:  "Action  anesthesique  de  I'orthoforme  dans  le  traitcmcnt 
par  I'injestion  iodee  de  I'hydrocele,"  Eef. :  Le  Scalpel,  1903,  No.  21. 

Bardet:  "Les  Intoxications  par  I'orthoforme,  le  meilleur  mode  de 
prescription  de  I'orthoforme,"  Bull.  d.  la  Soc.  d:  Therap.,  1904,  No.  9; 
also,  Nouveaux  Eemedes,  1904,  No.  11,  21. 

Murdoch:  "Further  Eemarks  on  Orthoform  in  the  Diagnosis  of 
Gastric  Ulcer,"  Med.  News,  1904,  No.  15. 

Audebert:    Trilune  med.,  1904,  No.  40. 

Tolnai:  "Einige  pulverformige  Antiseptika,"  Budapesii  Orvosi 
Ujsdg,  1905,  No.  11. 

Baumgarten:  "Therapeutische  Erfahrungen  auf  dem  Gebiete  der 
Ehinolaryngologie ;  Orthoform  und  Anaesthesin,"  Budapesii  Orvosi 
Ujsdg,  1905,  No.  13. 

Saxtorph-Stein :  "Behandlung  der  Larynxtuberkulose,"  Deut.  Med.- 
Zif}.,  1906,  No.  24. 

Schroder:  "Diagnose  und  Behandlung  des  chronischen  Magenge- 
schwUrs,"  Lancet  Clinic,  Dec.  15,  190G. 

Hoffman:  "Daueranasthesie  im  tuberkulosen  Kehlkopf,"  Munch. 
med.  Woch.,  1908,  No.  14. 

Limburger:  "Uber  Lokalanasthesie,"  Zahnarztliches  Centralbl., 
1908,  No.  4. 

Orthoform-New  Hydrochlorid. — Orthoform-new  hydrochlorid 
(C«H«03N.HC1) 
is  the  hydrochlorid  of  methyl  meta-amino-para-oxybenzoate.  It  is  a 
white,  crystalline  powder,  having  an  Indefinite  melting  point  and  an  acid 
reaction.  It  is  soluble  in  10  parts  of  water.  Its  reactions  are  the  same 
as  those  of  Orthoform-New,  except  that  it  gives  a  reaction  for  chlorids 
with  silver  nitrate  and  has  an  acid  reaction;  3.65  gm.  dissolved  in  50  c.  c. 
of  alcohol  require  not  less  than  17.8  c.  c.  nor  more  than  18  c.  c.  of 
normal  solution  of  sodium  hydroxid  to  produce  a  neutral  liquid.  Its  in- 
compatibilities are  the  same  as  those  of  Orthoform-New  {q.  v.). 

Actions  and  Uses. — The  actions,  uses,  and  dosage  of  this  compound 
are  similar  to  those  of  Orthoform-New  (q.  v.)  ;  but  it  is  freely  soluble  in 
water.  It  has  been  employed  hypodermically,  but  this  method  of  appli- 
cation is  not  always  satisfactory,  for  the  reason  that  solutions  are  in- 
clined to  be  somewhat  acid  and  have  been  known  to  produce  irritation  at 
the  site  of  injection. 

Orthonal. — The  name  is  given  to  a  local  anesthetic  intended  for 
dental  use.    It  consists  of  cocain  hydrochlorid,  0.5  gm. ;  alypin,  0.75  gm. ; 


798  ANESTHESIA 

adrenalin  solution  (1  ,to  1,000),  6  gni. ;  physiological  salt  solution, 
enough  to  make  100  gm.  It  is  put  up  in  ampules  holding  1  to  3  c.  e. ; 
1  to  3  c.  c.  are  used  subcutaneously  for  anesthesia,  according  to 
Schleieh's  infiltration  or  Oberst's  method. 

On  Orthonal,  see : 

Barry:  Zalindrztl.  Rundschau,  19,  No.  10;  Friedrich:  Berlin 
zahndrztl.  Halhmonatsschr.,  1911;  Sander-Calbe :  Zentr.  Zalinlieilh., 
Jf^,  No.  8;  Brandes:  Deut.  Monat.  Zalinlieilh.,  1910,  No.  3;  Schulze: 
Zahndrztl.  Rundschau,  19,  No.  27;  Seefeld:  Ihid.,  19,  No.  50;  Moses: 
Deut.  med.  Woch.,  37,  No.  46,  2138;  Eabow:  Ghem.-Ztg.,  1912,  No.  29, 
258 ;  Flury :    Z.  angew.  Chem.,  26,  No.  35,  242. 

Otis  Mixture. — Chloroform,  3  parts;  alcohol,  4  parts;  and  ethyl 
bromid,  1  part  (Miiller:  "Narkologie,"  1,  492).  Otis  employed  this 
mixture  extensively  in  general  and  obstetric  surgery. 

Ouabain. — Ouabain  (CjoH^gOia)  is  a  glucosid  from  the  ouabai  root, 
an  acocanthacese,  and  is  also  found  in  one  of  the  strophanthus  species 
(Strophanthus  gratus).  In  1882  Arnaud  obtained  from  an  unidentified 
species  of  the  genus  Acocanthera  a  crystalline  glucosid,  and,  in  1893, 
Lewin  separated  from  the  cocanthera  deflersii  an  amorphous  glucosid. 
Arnaud  assigned  to  ouabain  the  formula  CgoH^gOia-  Grley  (Compt. 
rend.  Soc.  biol.,  1895,  ii),  whose  statements  have  been  largely  corrobor- 
ated by  Sailer,  Lewin,  and  others,  reported  that  ouabain  was  a  local  an- 
esthetic, having  ten  times  the  power  of  cocain. 

On  ouabain  as  a  local  anesthetic,  see  Panas,  "Sur  Faction  anes- 
thesique  locale  da  la  strophantine  et  de  I'ouabaine,"  Bull,  de  VAcad.  de 
Med.  de  Paris,  1890,  No.  7. 

Strophanthus  glaber  contains  ouabain,  which,  according  to  Karsten 
(Compt.  rend.,  126,  346),  is  identical  with  Strophanthin  (q.  v.). 

Oxygen. — Gray  (1874)  found  oxygen  to  serve  as  an  anesthetic  for 
short  operations  (see  Richmond  Med.  Mon.,  June,  1879) ;  it  is  not  a 
true  anesthetic,  however, 

Oxysparteinum  Hydrochlorid. — The  hydrochlorid  of  oxyspartein,  an 
oxidation  product  of  the  alkaloid  spartein  from  Spartium  scoparium.  It 
forms  white  crystals,  melting  at  -|-  48-50°  C,  and  is  soluble  in  water  and 
alcohol.  It  is  used  to  prevent  cardiac  disturbances  during  chloroform 
narcosis. 

Pantopon  (Omnopon). — The  preparation  introduced  by  Sahli 
(Therap.  Monatsh.,  1909,  No.  1;  see,  also,  Pharm.  Centrh.,  50,  49),  un- 
der the  name  "Pantopon,"  is  said  to  contain  the  alkaloids  of  opium  in 
the  same  proportion  in  which  they  occur  in  nature  in  opium  itself 
(89.77  per  cent  alkaloids  as  hydrochlorids,  50  per  cent  of  which  is  mor- 
phin).  It  is  a  brownish  powder,  soluble  in  water,  forming  with  the  lat- 
ter a  brown  solution.  The  alkaloids  are  comlnned  with  hydrochloric 
acid.     The  variable  composition  of  opium  would  seem  to  render  it  al- 


A   LIST    OF    ANESTHETICS  799 

most  impossible  to  obtain  a  preparation  of  uniform  composition  and  of 
uniform  therapeutic  action  in  every  case,  and  further  experience  is  re- 
quired to  enable  us  to  decide  on  the  special  indications  of  pantopon. 
Sahli  stated  that  it  could  not  be  regarded  as  an  exact  substitute  for 
morphin;  but  Eodari  (Therap.  Monatsh.,  1909,  540)  came  to  the  con- 
clusion that  the  narcotic  and  hypnotic  action  observed  clinically  by 
Sahli  could  also  be  obtained  on  animals,  and  that  this  action  determined 
its  chief  advantage.  The  pharmacological  studies  of  Wertheimer-Eaf- 
falovich  (Deut.  med.  Woch.,  1910,  No.  37)  demonstrate  that  pantopon 
has  a  decided  hypnotic  action  on  animals  and  affects  the  respiratory  cen- 
ter less  than  morphin.  Similar  results  were  obtained  by  Loewy  aiid 
Bergien  {Miinch.  med.  Woch.,  1910,  No.  46),  the  latter  also  showing 
that  pantopon  had  no  effect  upon  the  circulation.  These  characteristics 
indicated  that  pantopon  would  be  a  suitable  substitute  for  morphin  in 
scopolamin-morphin  anesthesia,  and  Brlistlein  (Correspondenz.  f. 
schweizer  Aerzte,  1910,  No.  26)  proposed  its  use  for  this  purpose. 
Grafenberg  (Deut.  med.  Wocli.,  1910,  Nos.  34  and  39)  considered  that 
the  scopolamin  might  be  omitted.  He  also  tried  general  anesthesia  by 
means  of  ethyl  ether  with  pantopon  injections  alone,  and  procured  very 
satisfactory  results. 

On  the  action  of  pantopon  on  the  digestive  canal,  see  Cohnheim  and 
Modrakowski:  Z.  pliysiol.  Chem.,  71,  273.  Brlistlein  {Corr.-Blatt.  f. 
schweiz.  Aerzte,  J^O,  826)  reported  that  scopolamin  hydrobromid  in  75 
parts  of  water  and  25  parts  of  glycerol  containing  2  per  cent  of  pantopon 
made  a  clear  solution  which  was  narcotic.  He  considered  that  pantopon 
was  entirely  devoid  of  disturbing  substances  and  side  actions.  German 
Patent  229,905,  of  October  10,  1909,  of  F.  Hoffman-La  Eoche  &  Co., 
claims  a  process  for  the  manufacture  of  preparations  containing  all  the 
alkaloids  of  opium  in  a  readily  soluble  form  suitable  for  subcutaneous 
injection.  An  aqueous  acid  extract  of  opium  is  precipitated  with  alka- 
lies, the  alkaline  precipitant,  separated  from  the  precipitate,  is  shaken 
with  organic  solvents,  the  alkaloids  are  removed  by  shaking  out  with 
acids  yielding  water-soluble  salts,  the  alkaloids  precipitated  with  alkalies 
and  purified  are  dissolved  in  the  acid  alkaloid  solution,  and  the  solution 
is  dried.  The  products  are  stated  to  give  the  reactions  for  morphin,  nar- 
cotin,  papaverin,  and  thebain. 

On  morphin-free  pantopon,  see  Winternitz,  Miinch.  med.  Woch.,  59, 
853. 

On  pantopon  anesthesia,  see  the  following : 

Sahli:  Miinch.  med.  Woch.,  1909,  No.  26;  Therap.  Monatsh.,  1909, 
No.  1. 

Hallervorden :     Therap.  der  Gegenwart,  1910,  No.  5,  206. 

Heimann:     Miinch.  med.  Woch.,  1910,  No.  7,  357.      ' 

Eodari:    Therap.  Monatsh.,  Oct.,  1909. 


800  ANESTHESIA 

Gottlieb  and  v.  d.  Eeckhart:    "Festsclir.  f.  Schmiedelerg,"  1910,  235. 

Becker:    Reiclis-Med.-Anz.,  1910,  No.  18,  273. 

Witowski:    Arch.  f.  ex  per.  Path.  u.  Pharmakol.,  17. 

Jager:    Munch,  med.  Woch.,  1910,  2238. 

Eaffalovitch :    Deut.  med.  Woch.,  1910. 

Briistlein:  Correspondenz.  f.  schweiz.  Aerzte,  1910;  Zentr.  Chirurg., 
1911,  No.  10,  345. 

Ewald :  Berl.  Min.  Woch.,  1910,  No.  35 ;  Munch,  med.  Woch.,  1910, 
No.  25,  1326. 

Burgi:    Deut.  med.  Woch.,  1910. 

Sahli:  Zentralhl.  f.  d.  gesammte  Therapie,  1909;  Berl.  Min.  Woch., 
1910,  No.  35,  1G09. 

Griifenberg:    Deut.  med.  Woch.,  1910,  No.  34,  1569. 

Doblin:    Therap.  Monatsh.,  1911, 'No.  4,  21C). 

Leipoldt:    Lancet,  Feb.  11,  1911,  3.68. 

Zollinger:     Correspondenz.  f.  schweiz.  Aerzte,  1911,  No.  10. 

Eobertson:     Lancet,  Oct.  7,  1911. 

Fowelin:    Zentr.  Chirurg.,  1911,  No.  27,  921. 

Hellman:    Am.  Med.,  n.  s.,  7,  No.  1,  39. 

Voigt:     Therap.  Monatsh.,  1911,  601. 

Haymann:    Miinch.  med.  Woch.,  1911,  No.  2,  82. 

In  employing  omnopon  in  the  induction  of  anesthesia  before  opera- 
tions, Leipoldt  found  that  omnopon  injections  are  more  effectual  than  a 
combination  of  Omnopon  and  Scopolamin  (q.  v.),  since  it  occasions 
neither  nausea  nor  vomiting. 

Krauss:    Zentr.  Chirurg.,  1911,  No.  20. 

Zahradnicky:    Ibid.,  1911,  No.  30,  1017. 

Aulhorn:    Miinch.  med.  Woch.,  1911,  No.  12,  618. 

Johannsen:     Zentr.  Gyndk.,  1911,  No.  19,  702. 

Zeller:    Miinch.  med.  Woch.,  1911,  No.  25,  1355. 

Kolde:    75iU,  1911,  No.  28,  1499. 
.        Simon:    76td,  1911,  No.  32,  1725. 

Dornbliith:     Deut.  med.  Woch.,  1911,  No.  15,  697. 

Kafemann:     Med.  Klin.,  1911,  No.  26,  1002. 

Heinsius:    Berl.  klin.  Woch.,  1911,  No.  41,  1837. 

Anneler:    Arch.  Fliarm.,  250,  186. 

Mannich  and  Schwedes:    Apoth.-Ztg.,  2S,  82. 

For  other  preparations  containing  the  alkaloids  of  opium,  see  Isopon, 
Nealpon,  Opiopon,  Opon,  and  Summopon. 

Paraldehyd. — This  compound  was  found  to  act  similarly  to  chloral, 
but  caused  deep  sleep  and  no  convulsive  movements.  (See  Archiv  f. 
exper.  Pathol,  u.  Pharmakol.,  1882.)  Noto  {New  Orleans  Med.  and 
Chir.  J.,  1900,  No.  9)  believed  that  paraldehyd  was  a  remedy  which, 
when  administered  internally  in  hypnotic  doses  of  2  to  3  gm.,  30  minutes 


A   LIRT    OF    ANESTHETICS  801 

to  one  hour  previous  to  narcotization  l)y  cliloroform,  completely  divested 
the  latter  of  its  attending  dangers.  'I'he  ancstlietic  properties  of  paralde- 
hyd  are  more  marked  than  those  of  acetaidehyd  ;  it  is  less  toxic  than  me- 
taldehyd.  It  acts  first  on  the  higher  cerebral  centers  and  then  oji  the 
other  parts  of  the  central  nervous  system,  finally  causing  spinal  anes- 
thesia and  death.  It  is  said  to  have  no  depressant  action  on  the  licart. 
However,  it  possesses  a  very  unpleasant  odor  and  taste,  and  has  an  ir- 
ritant action  on  the  gastric  mucosa  (Francis  and  Fortescue-Brickdalo: 
"The  Chemical  Basis  of  Pharmacology,^'  1908,  107-8). 

On  employment  of  paraldehyd  in  intravenous  anesthesia,  see,  also: 
Lancet,  Sept.  21,  1913,  818;  Nov.  2,  1912,  1220. 

Para-amidobenzoic  Acid  Ethyl  Ester. — A  white  powder,  melting  at 
-f-  90-91°  C,  and  possessing  the  following  composition: 

NH2.CoH,.COOC2l-I,. 
It  is  used  as  a  local  anesthetic. 

Para-amidobenzoic  Acid  Isobutyl  Ester. — Soft,  colorless  needles, 
m.elting  at  -|-"65°  C,  possessing  anesthetic  properties. 

Paraneplirin. — An  extract  from  the  suprarenal  glands  which  is  free 
from  albumoses  and  peptones.  In  dental  practice  it  is  employed  in  com- 
bination with  tropacocain;  see,  also,  combinations  which  follow  {infra). 

Paranephrin-cocain  Mixture. — A  dental  anesthetic  consisting  of 
paraneplirin  1:  1,000  and  1  per  cent  of  cocain. 

Paranephrin-cocain-subcutin. — A  hemostatic  local  anesthetic  for  sur- 
gical and  dental  jDractice. 

Paranephrin-novo-subcutin. — This  preparation  contains  novocain, 
and  is  employed  as  a  general  as  well  as  a  local  anesthetic,  especially  in 
dental  surgery. 

Pate  de  Vide. — Bonbons  containing  aconitin,  heroin,  and  stovain. 

Pental  (Trimethylethylene;  beta-isoamylene). — Pental  [(0113)20  = 
OH'.OH,]  is  an  anesthetic  which  has  beeiL  used  in  minor  surgical  cases, 
as  tooth  extraction;  but  it  possesses  toxic  properties,  and  hence  is  not 
favored.  Pental  was  highly  recommended  by  W.  Lombardino  as  an 
anesthetic  of  great  practical  value.  Wood  and  Oerna  have  shown,  how- 
ever, that  it  acts  on  lower  animals  as  a  powerful  cardiac  depressant,  and 
is  probably  a  dangerous  anesthetic.  That  it  possesses  real  danger  is 
shown  in  the  statistics  gathered  by  Gurlt,  who  recorded  that  there  were 
6  deaths  in  600  pental  narcoses;  and,  moreover,  Kleindienst  found  that 
very  frequently  in  man  severe  albuminuria  results  and  that  not  infre- 
quently hematuria  and  hemoglobinuria  occur  three  or  four  days  after 
pental  narcoses. 

On  the  employment  of  pental,  see  the  following: 

Breuer  and  Lindner :  "Ueber  Pentalnarkosen'' ;  v.  Hacker's  "Ohir. 
Beitr.  a.  d.  Erzherzogin-Sophien-Spital,"  Vienna,  1892;  Zentr.  Chir.^ 
1893,91.- 


802  ANESTHESIA 

Gurlt :  "Zur  Narkotisierungsstatistik/'  Verh.  d.  XXVI.  Deut.  Chirur- 
genhongr.,  1897,  Teil  ii,  202. 

Hollander:  Therap.  Monatsli.,  1891  and  1892;  Deut.  med.  Woch., 
1892,  757;  J.  f.  Zahnheillc.,  1893;  Zentr.  Cliir.,  1893,  517. 

Kleinschmidt :  "Ueber  Pental  als  Anasthetikum,"  Deut.  Z.  f.  CJiir., 
35,  333.     , 

Philipp:  "Ueber  Pentalnarkose  in  der  Chirurgie,"  Yerh.  d.  XXL 
Deut.  Chirurgenhongr.,  1892,  Teil  ii,  367. 

Van  Eeysschoot:  "Contribution  a  I'etude  experimentale  du  pental," 
Gand,  1892. 

Eieth :     "Ueber  die  Pentalnarkose,"  v.  Brims'  Beitr.,  1893,  10,  189. 

Von  Rogner:  "Das  Pental  in  der  chirurgischen  Praxis,"  Wiener 
med.  Presse,  1891,  No.  51;  Zentr.  Cliir.,  1892,  93. 

Weber:  "Pental,  ein  nenes  Anasthetikum,"  Dissertation,  Halle, 
1891 ;  Miincli.  med.  Woch.,  1892,  No.  7. 

Pentane  (Amyl  Hydrid). — A  liquid  hydrocarbon  from  naphtha,  pro- 
posed as  an  anesthetic.     See  Hydramyl. 

Pentylene. — See  Hydramyl. 

Peronin. — This  morphin  derivative,  benzyl-morphin  hydrochlorid 
[Ci^HigNOa.O.CeHg.CHg.HCl]  has  been  shown  to  act  as  a  local  anes- 
thetic for  the  eye.  Buffalini  (Settimana  med.,  1899,  No.  27)  found 
that  the  instillation  of  a  few  drops  of  a  luke-warm  1  to  2  per  cent  solu- 
tion of  peronin  into  the  conjunctival  sac  induced  complete  and  deep  an- 
esthesia of  the  cornea  enduring  for  many  hours.  Guaita  {Hid.,  1899, 
No.  40)  confirmed  the  statements  of  Buffalini. 

On  Peronin  as  a  local  anesthetic,  see  the  following  literature: 

Buffalini:  "La  Peronina,  nuovo  anestesico  locale,"  Settimana  med., 
1899,  No.  27;  Virchow-Hirsch's  Jahresber.,  1899,  1,  393. 

Guaita:  "Sopra  I'azione  anestetica  locale  della  peronina,"  Ann.  di 
Farm.acoierap.,  1899,  No.  9,  10. 

Pierard:  "Quelques  experiences  sur  Paction  physiologique  de  la 
Peronine,"  Ann.  de  la  Soc.  des  Sci.  med.  de  Bruxelles,  1899,  No.  8. 

Phenol. — See  Carbolic  Acid. 

Phenol  Camphor. — See  Camphor,  Phenylated. 

Phenolcocain. — See  Cocainum  Phenylicum. 

Phenyl-urethane. — This  compound,  also  known  as  euphorin,  has  the 
following  formula: 

/OCH26 

CO 

\ 

^NH.CsHb 

It  forms  colorless,  crystalline  needles,  melting  at  +  49°-50°    C,  and 
dissolving  in  alcohol  and  ethyl  ether.     Stroll  (Miinch.  med.  Woch.,  1907, 


A   LIST    OF    ANESTHETICS  803 

No.  45,  2262)  drew  attention  to  the  use  of  phenyl-urethane  in  the  treat- 
ment of  painful  ulcers  of  the  foot ;  in  his  experience  the  preparation  was 
superior  in  anesthetic  power  even  to  anesthesin  and  orthoforra. 

Phenjrphrin. — A  dental  local  anesthetic  containing,  per  c.  c.  of  physi- 
ological salt  solution,  0.02  gm.  alypin  and  0.1  gm.  "Nebennierenextrak- 
losung"   (1:1,000). 

Phcenixin. — Carbon  Tetrachlorid  (q.v.). 

Plecavol. — A  tooth  cement.  A  flask  with  plevacol  powder :  Para- 
amidobenzoyleugenol,  eugenol,  zinc  oxid,  zinc  sulphate,  and  gum  arabic. 
A  flask  containing  a  solution  of  tricresol-formalin  is  also  required.  An- 
esthetic and  antiseptic  acting  pulpa-capping  material  and  fllling  material 
for  roots,  used  in  dentistry.  It  is  said  to  act  without  irritation,  conserv- 
ing the  pulpa,  and  hardening  in  a  short  time. 

Pleistopon. — Narcotin-free  Pantopon  (q.  v.). 

Polychloral. — This  is  obtained  by  adding  pyridin,  drop  by  drop,  to 
chloral,  washing  out  the  resulting  solid  with  dilute  hydrochloric  acid  and 
then  drying.  It  dissolves  slowly  in  water,  more  quickly  in  alcohol,  form- 
ing chloral  hydrate  and  chloral  alcoholate  respectively.  An  anesthetic 
and  hypnotic. 

Polychlorated  Hydrochloric  Ether. — See  Ethyl  Chlorid  Polychlo- 
rated. 

Potassocain  or  Pottasocain, — This  contains  cocain  dissolved  in  alcohol 
and  ether. 

Propesin  (Propasin). — A  German  local  anesthetic;  it  is  the  propyl 

ester  of  paramido-benzoic  acid,  NH2<^  \cOOC3H7.      It  is   a  white 

crystalline  powder  which  melts  at  +  73-74°  C.  It  is  readily  soluble  in 
alcohol,  ether,  and  chloroform,  but  dissolves  with  difficulty  in  water. 
Said  to  be  practically  nontoxic,  and  to  act  very  promptly  and  effectively 
on  mucous  membranes. 

On  propesin,  see  the  following: 

Kluge:   Therap.  Monatsli.,  Feb.,  1909,  77. 

Stiirmer  and  Liiders:    Deut.  med.  Woch.,  1908,  No.  53,  2310. 

Dietrich :    Deut.  zahndrztlichen  Ztg.,  1910,  No.  16. 

Perl:    Med.  Klinilc,  1909,  No.  50,  1892. 

On  the  use  of  propesin  in  urology  and  gynecology,  see  Medizin. 
Klinih,  1908,  1769,  Kluge  states  that  the  only  disadvantage  of  propesin 
is  that  its  slight  solubility  in  water  renders  it  unsuitable  for  subcutaneous 
injection. 

Propesin-colloid  contains,  according  to  Pliarni.  Ztg.,  55,  858,  20  per 
cent  propesin,  72.5  per  cent  glycerin,  2.5  per  cent  starch,  and  5  per  cent 
ethyl  alcohol.     On  propesinol,  see  linger:  Apoth.-Ztg.,  27,  1023. 

See  Dipropesin. 


804  ANESTHESIA 

Propion. — Diethyl  ketone  (C2H5.CO.C2H5),  also  known  as  metace- 
tone,  propione,  and  ethylpropionyl,  is  a  colorless,  mobile  liquid,  posses- 
sing an  acetone  odor;  it  boils  at  +  101°  C.  Propion  was  recommended 
as  a  hypnotizing  agent  by  Albanese  and  Barabini  {Ann.  di  chem.  e 
farmaeol.,  Feb.,  1893,  124;  April,  1892,  225),  who  observed  that  it 
caused,  when  administered  to  dogs  and  rabbits  in  doses  of  1.0  to  1.5  gm., 
deep,  tranquil,  and  enduring  sleep,  the  compound  being  readily  absorbed 
when  introduced  into  the  stomach  or  rectum,  or  when  injected  in  sub- 
cutaneous tissue.  The  inhalation  of  diethyl  ketone  also  induced  sleep, 
but  this  property  did  not  seem  to  be  of  any  practical  value,  since,  in  this 
method  of  application,  the  narcosis  was  effected  too  slowly.  See,  also, 
Noera:  Arch,  di  farmacol.  e  terap.,  1896,  4,  f.  ii,  12.  The  solubility  of 
propion  in  water  is  not  great  and,  in  addition,  its  taste  is  impleasant. 

Puff-Bali. — In  1853,  Eichardson,  having  learned  that  the  "smoke" 
(cloud  of  brov/n  dust-like  spores)  of  that  curious  fungus,  the  common 
puff-ball,  had  been  used  by  country  folk  for  the  stupefaction  of  bees, 
conceived  the  idea  that  it  might  be  used  as  a  general  anesthetic.  He 
conducted  experiments  upon  dogs,  cats,  and  rabbits,  and  in  one  case  re- 
moved a  tumor  from  a  dog  without  observing  any  indications  of  pain 
during  the  operation  {Med.  Times  and  Gaz.,  1853,  610).  To  quote 
Lyman  ("Artificial  Anesthesia  and  Anesthetics,"  1881,  328),  when  a 
moderate  quantity  of  the  smoke  was  gradually  inhaled,  anesthesia  ap- 
peared and  disappeared  slowly.  The  animal  exhibited  all  of  the  symp- 
toms of  intoxication,  accompanied  by  convulsions  and  sometimes  by 
vomiting.  Life  ceased  by  degrees;  after  the  induction  of  complete  in- 
sensibility, a  dog  might  inhale  the  smoke  for  twenty  minutes  or  even 
half  an  hour  before  death  resulted.  Bespiration  always  ceased  before 
the  action  of  the  heart.  Herapath  made  experiments  which  proved  that 
the  active  agent  in  producing  the  preceding  phenomena  was  carbon  di- 
oxid,  generated  during  combustion;  his  conclusion,  confirmed  by  Snow, 
was  accepted  by  Eichardson.  It  would  seem  from  these  experiments 
{Phil.  Mag.,  July,  1855)  that  the  anesthetic  effects  are  not  owing  to  a 
narcotic.    See  Carl)on  Dioxid. 

Pyridin. — This  is  a  liquid  of  a  powerful  odor,  the  vapor  of  which,  if 
inhaled,  stimulates  the  fifth  nerve  and  produces  dyspnea,  then  slow, 
shallow  breathing,  and  finally  sleep.  In  very  large  doses  it  paralyzes  the 
sensorium,  producing  complete  anesthesia  and  abolition  of  reflexes; 
smaller  doses  may  inhibit  respiration.  Piperidin  and  pyrollidin  have 
much  the  same  action  (Prancis  and  Portescue-Brickdale's  "The  Chemical 
Basis  of  Pharmacology,"  1908,  250). 

Pyrocain. — A  guaiacol-benzyl  ester,  said  to  be  a  nontoxic  local  anes- 
thetic. 

Pyrrol  (Pyrrhol). — Pyrrol  was  experimented  with  by  the  Committee 
of  the  British  Medical  Association.     In  the  frog  it  produced  anesthesia 


A   LIST    OF    ANESTHETICS  805 

with  considerably  less  rapidity  than  chloroform,  and  great  excitement 
and  muscular  spasms  preceded  complete  anesthesia.  Its  hypodermatic 
administration  to  three  young  rabbits  produced  spasmodic  movements, 
principally  involving  the  jaws  and  fore-paws;  these  rabbits  were  not 
decidedly  anesthetized. 

ftuinin  Alkaloids. — Morgenroth  and  Ginsberg  (Berl.  Jclin.  Woch., 
50,  No.  8)  investigated  the  effect  of  the  quinin  alkaloids  upon  the  cor- 
nea. The  compounds  studied  combine  with  ethylhydrocuprein  to  form 
isopropyl,  isobutyl,  and  isoamyl  hydrocuprein.  A  3  per  cent  solution  of 
quinin  hydrochlorid  and  1.0  to  1.25  per  cent  solutions  of  hydroquinin 
and  ethylhydrocuprein  hydrochlorid  produced  complete  anesthesia  of  the 
cornea;  with  the  transformation  of  the  ethyl  to  the  propyl  compound,  a 
marked  increase  in  anesthetic  action  resulted,  for  with  isoaraylhydro- 
cuprein  a  0.1  to  0.125  per  cent  solution  was  sufficient.  Isoamylhydro- 
cuprein  proved  to  be  at  least  20  to  25  times  more  active  than  cocain. 

Quinin  and  Urea  Hydrochlorid  (Quininge  et  Urese  Hydrochloridum ; 
Chininum  bihydrochloricum  Carbamidum). — Quinin  and  urea  hydro- 
chlorid (C2oH2iK202.HCl  +  Cri4N20.HCl+  5HoO)  is  a  compound  of 
quinin  hydrochlorid  and  urea  hydrochlorid  containing  approximately  GO 
per  cent  of  anhydrous  quinin.  The  preparation  is  made  by  dissolving 
400  parts  quinin  hydrochlorid  in  300  parts  of  dilute  hydrochloric  acid, 
sp.  gr.  1.061,  mixing  the  solution  with  60  to  61  parts  of  pure  urea 
[C0(NH2)2],  warming  the  mixture  until  dissolved,  filtering  it  through 
glass  wool  and  setting  the  filtrate  aside  for  crystallization.  After  twenty- 
four  hours  the  crystals  are  brought  on  a  filter,  drained,  washed  with 
very  cold  distilled  water,  spread  on  flat  plates  and  dried  at  room  tem- 
perature. The  mother-liquor  is  evaporated  and  again  set  aside  for 
crystallization.  The  second  mother-liquid,  which  is  colored  brown,  is 
exposed  in  a  dish  to  spontaneous  evaporation,  during  which  all  of  the 
double  salt  of  quinin  slowly  crystallizes  out  and  may  be  separated. 

The  hydrochlorid  of  quinin  and  urea  crystallizes  from  hot  solutions 
in  hard,  white,  interlaced  four-sided  prisms.  On  spontaneous  evapora- 
tion of  a  concentrated  solution,  very  large  transparent  prisms  are  found. 
The  salt  dissolves  at  ordinary  temperature  in  its  own  weight  of  water, 
forming  a  somewhat  viscid  straw-colored  liquid,  not  altered  by  exposure 
to  light.  During  its  solution  a  marked  lowering  of  temperature  occurs. 
It  is  not  hygroscopic  and  is  unalterable  in  the  air,  excepting  that  when 
warmed  the  crystals  lose  their  transparency  and  become  yellowish.  They 
fuse  at  from  70°  to  75°  C.  (158°  to  167°  F.)  with  the  loss  of  10 
per  cent  of  water,  forming  a  yellowish  liquid  which  congeals,  on  cooling, 
to  a  yellow  mass.  If  this  mass  is  allowed  to  stand  in  the  air,  it  takes  up 
water,  after  a  few  days,  equal  in  amount  to  that  expelled,  and  again  be- 
comes white.  If  the  melted  salt  is  dissolved  in  water,  it  may  be  com- 
pletely recovered  in  a  crystalline  form.    It  is  also  soluble  in  alcohol,  and 


806  ANESTHESIA 

from  this  solution  a  salt  of  somewhat  variable  composition  is  precipitated 
by  ether.  It  is  soluble  in  about  800  parts  of  chloroform.  Its  water  solu- 
tions are  of  a  strong  acid  reaction.  A  solution  of  the  salt  in  water 
(1  to  20)  shows  no  fluorescence;  but  if  one  drop  of  this  solution  is  added 
to  10  c.  c.  of  distilled  water  in  a  test  tube,  a  vivid  blue  fluorescence  is 
developed."  On  drying  the  salt  at  -(-  125°  C.  to  constant  weight  and  cool- 
ing in  a  desiccator,  it  should  not  lose  more  than  16.5  per  cent  of  its 
weight  (corresponding  to  five  molecules  of  water  of  crystallization).  On 
ignition,  the  pure  salt  is  slowly  consumed,  leaving  no  residue.  Am- 
monia water,  alkaline  hydroxids  or  alkali  carbonates  throw  down  from 
the  water  solution  of  quinin  and  urea  hydrochlorid  a  white  precipitate 
of  alkaloidal  quinin,  which,  when  carefully  washed  with  cold  distilled 
water  until  free  from  chlorids,  and  dried  at  a  low  temperature,  should 
conform  to  the  reactions  and  tests  given  in  the  United  States  Pharma- 
copoeia under  quinin.  One  gram  dissolved  in  2  c.  c.  of  distilled  water, 
and  well  shaken  in  a  stoppered  test-tube  with  6  c.  c.  of  ether  and  2  c.  c. 
of  10  per  cent  ammonia  water,  should  be  dissolved  completely,  and  no 
crystals  should  separate  out  from  the  ethereal  solution  on  standing  for 
six  hours.  If  the  ethereal  stratum  is  removed  to  a  tared  beaker,  and 
the  contents  of  the  test-tube  are  washed  successively  with  three  portions 
of  5  c.  c.  each  of  ether  and  these  ether  washings  be  also  added  to  the 
tared  beaker,  the  alkaloidal  quinin  remaining  after  evaporating  off  the 
ether,  dried  at  -f-  125°  C.  to  constant  weight,  shovild  weigh  not  less  than 
0.592  gm.  On  the  chemical  and  physical  properties  of  Quinin  and  Urea 
Hydrochlorid,  see  Schaefer:  The  Drug.  Cir.,  Feb.,  1910. 

Actions  and  Uses. — Quinin  and  urea  hydrochlorid  has  the  actions  of 
quinin.  It  is  non-irritating  when  injected  hypodermically.  Eecent  in- 
vestigations have  shown  that,  when  injected  hypodermically  or  when  ap- 
plied locally  to  mucous  membranes,  it  exerts  an  anesthetic  action  similar 
to  that  of  cocain.  It  is  reported  that  the  anesthesia  is  in  some  cases 
prolonged  for  several  days.  Sylvester,  of  Wellston,  Ohio,  is  reported  as 
having  employed  quinin  for  more  than  twenty  years  as  an  anesthetic  to 
denuded  and  mucous  surfaces,  but  not  hypodermically.  In  July,  1896, 
before  the  Chautauqua  County,  N.  Y.,  Medical  Society,  Griswold  reported 
on  its  hypodermic  use  as  an  efficient  local  anesthetic.  It  was  Henry 
Thibault  who  found  that  quinin  and  urea  hydrochlorid,  employed  ex- 
tensively in  the  South  for  the  hypodermic  treatment  of  malaria,  rendered 
the  site  of  the  injection  anesthetic  for  a  considerable  period.  He  experi- 
mented further  and  learned  that  1  to  2  per  cent  solutions  produced  local 
anesthesia  which  lasted  from  1  to  6  hours  and  proved  to  be  safer  than 
cocain. 

On  the  use  of  the  preparation  in  various  operations,  consult  the  fol- 
lowing : 

Hertzler,  Brewster,  and  Eogers:   J.  Am.  Med.  Assn.,  Oct.  23,  1909, 


A   LIST    OF    ANESTHETICS  807 

1393;  The  Prescriher,  1910,  19;  Klin.-Uierap.  WocUenschrifl,  1910,  96. 

MacCampbell :    J.  Am.  Med.  Assn.,  May  14,  1910. 

Hertzler:   Ibid.,  April  23,  1910,  1375;  and  June  11,  1910,  1940. 

Hirschman:  Lancet-Clinic,  July  9,  1910. 

Med.  Council,  April,  1910,  IIG;  May,  1910. 

Green:   J.  Am.  Med.  Assn.,  June  11,  1910. 

Merck's  "Eeport,"  Nov.,  1911,  356. 

Ellis:    Therap.  Notes,  January,  1912,  7. 

These  contributions  show  that  subcutaneous  injections  of  a  1  to  2  per 
cent  solution  of  quinin  hydrochloro-carbamid  and  the  local  application 
of  a  10  to  20  per  cent  solution  occasionally  have  a  better  anesthetic  action 
than  cocain.     See  Ghevannes  Local  Anesthetic. 

Dosage. — The  same  as  quinin.  For  the  production  of  local  anes- 
thesia, injections  of  a  solution  of  from  ^  to  1  per  cent  strength  are 
used.  The  i^  per  cent  solution  is  said  to  be  free  from  the  risk  of  pro- 
ducing fibrous  indurations,  which  sometimes  occur  with  the  stronger 
solution.  For  application  to  mucous  membranes  solutions  varying  in 
strength  from  10  to  20  per  cent  should  be  used. 

Radestock's  Mixture. — An  anesthetic  mixture  of  chloroform,  2  parts, 
and  ethyl  ether,  3  parts  (Miiller,  "Narkologie,"  1,  493). 

Radikal-Anasthetikum  Apotheker  Maier. — A  solution  containing  co- 
cain, phenol,  iodin,  and  pyrazolin. 

Radinin. — A  preparation  insensitive  to  light  and  air ;  it  will  keep  in 
a  1  per  cent  cocain  solution  without  adrenalin. 

Rapid  Respiration,  Anesthesia  by. — Bonwill  and  Hewson  called  at- 
tention to  a  form  of  insensibility  to  pain  induced  by  rapid  respiration, 
and  the  matter  was  discussed  by  the  Philadelphia  County  Medical  So- 
ciety {Med.  Rec,  Aug.  21,  1880).  Bonwill  and  Lee  reported  that  the 
best  method  of  producing  this  kind  of  analgesia  was  by  causing  the 
patient  to  lie  upon  the  side,  with  a  handkerchief  over  the  eyes  in  order 
to  avoid  distraction  of  the  attention.  He  was  then  directed  to  breathe 
about  one  hundred  times  per  minute,  expelling  the  air  by  a  succession  of 
puffing  expirations.  After  from  two  to  five  minutes  of  this  exercise, 
there  was  developed  a  degree  of  insensibility  to  pain  which  persisted  for 
as  long  as  thirty  seconds.  The  movements  of  the  heart  were  accelerated 
and  the  force  of  the  pulse  was  diminished.  Consciousness  and  the  sense 
of  touch  were  not  abolished.  After  the  production  of  this  condition,  a 
smaller  quantity  than  usual  of  the  ordinary  anesthetics  Avere  required 
to  produce  complete  insensibility.  For  a  discussion  of  this  method,  see 
Lyman :  Loc.  cit. 

For  a  consideration  of  superventilation  by  means  of  oxygen,  see 
Chapter  11. 

Reichel's  Zahnschmerzstillende  Tropf  en. — A  Japanese  peppermint  oil 
free  from  menthol,  also  known  as  "Poho  Oil." 


808  ANESTHESIA 

Renocain. — An  adrenalin  solution  containing  cocain,  intended  for 
use  as  a  local  anesthetic. 

Renoform. — The  active  principle  of  the  suprarenal  gland.  It  is  a 
white,  crystalline  powder,  difficultly  soluble  in  cold  water,  easily  soluble 
in  acidified  water;  used  in  operations  for  localizing  anesthetics,  in  com- 
bination therewith. 

Rhigolene. — A  petroleum  ether  of  low  boiling  point.  Ehigolene  was 
introduced  by  Bigelow  in  18C6.    See  JEtlier  Anwstheticus  (Koenig). 

Rhinosol. — A  hay-fever  remedy  containing  Anesthesin  (q.  v.)  and 
paranephrin. 

Richardson's  Methylen  Chlorid. — A  mixture  of  chloroform  and 
methyl  alcohol. 

Richardson's  Mixture. — Chloroform,  2  parts;  alcohol,  2  parts;  and 
ethyl  ether,  3  parts  (Mliller,  "JSTarkologie,"  1,  492).  Eichardson  (Sci. 
Am.  SuppL,  No.  51G,  8240)  said,  in  reference  to  the  varying  proportions 
of  alcohol,  chloroform,  and  etlier  used  by  different  administrators  in 
compounding  A.  C.  E.  Mixture,  that  he  thought  that  4  parts  ether,  2 
parts  chloroform,  and  2  parts  alcohol,  by  fluid  measure,  were  the  best 
proportions,  and  that  it  was  "altogether  a  very  good  mixture." 

Robiol. — Eobiol  and  Novorobiol  are  combinations  of  suprarenin  with 
local  anesthetics  (Flury:  Z.  angeiu.  Chem.,  26,  242). 

Royal  Medical  and  Chimrgical  Society  Committee  Mixture. — Alcohol 
(sp.  gr.,  0.838),  1  part;  chloroform  (sp.  gr.,  1.497),  2  parts;  ether 
(sp.  gr.,  0.735),  3  parts  (Hewitt:  "Anesthetics  and  Their  Administra- 
tion," 3rd  ed.,  406). 

Sal  Anaestheticum  Schleichii. — A  varying  mixture  of  cocain  hydro- 
chlorid,  morphin  hydrochlorid,  and  sodium  chlorid,  to  induce  anesthesia 
by  infiltration  according  to  the  method  of  Schleich.  In  1894  Schleich 
("Schmerzlose  Operationen,"'-  Berlin,  1894)  first  propounded  the  doc- 
trine of  anesthesia  by  artificial  edematization  of  the  tissues  by  means  of 
morphin-cocain  injection.  A  number  of  papers  were  subsequently  pub- 
lished on  the  practical  aspects  of  the  subject :  Krecke :  Munch,  med. 
Wocli.,  1897,  No.  42;  Eeichold:  lUd.,  1167;  Briegleb :  Therap.  Monatsh., 
1897,  No.  12,  651;  Haberern:  Ungar.  med.  Presse,  1897,  No.  46,  1094; 
Simon-Cohn:  Berl,  klin.  ^¥ocll.,  1897,  No.  30. 

The  anesthetizing  mixture  originally  proposed  by  Schleich  was  of 
three  different  degrees  of  strength,  namely: 

1.  Sal  ansestheticum  Schleichii  I  (strong): 

Cocain  Hydrochlorid 0.2      (gr.  3) ; 

Morphin  Hydrochlorid 0 .025  (gr.  1/3) ; 

Sodium  Chlorid 0.2      (gr.  3). 

2.  Sal  ansestheticum  Schleichii  II  (normal) : 

Cocain  Hydrochlorid 0.1       (gr.  1  2/3) ; 

Morphin  Hydrochlorid 0.025  (gr.  1/3); 

Sodium  Chlorid 0.2      (gr.  3). 


A   LIST    OF    ANESTHETICS  809 

3.  Sal  anaestheticum  Schleichii  III  (weak) : 

Cocain  Hydrochloric! 0.01     (gr.  1/6) ; 

Morphin  Hydrochloric! 0.005  (gr.  1/12); 

Sodium  Chlorid 0.2      (gr.  3). 

Each  of  the  three  mixed  powders  was  dissolved  shortly  before  use  in 
100  c.  c.  of  boiled  distilled  water,  and  these  solutions  were  directed  to 
be  used  only  when  cold,  since  otherwise  their  anesthetic  properties 
were  lost.  It  was  known  in  1897  that  cocain  could  be  suitably  replaced 
by  Tropacocain  {q.  v.).  Ethyl  chlorid  was  usually  employed  as  a  pre- 
cursor of  infiltration  anesthesia.  In  1898  Custer  [Munch,  med.  Woch., 
1898,  ISTo.  22)  showed  that  tropacocain  was  decideclly  preferable  to  co- 
cain, especially  when  required  for  Schleich's  infiltration  method.  The 
solutions  required  for  infiltration  were  stated  to  be  of  the  same  degree 
of  concentration  as  cocain  hydrochlorid,  i.  e.,  0.2  per  cent  in  the  case  of 
solution  I;  0.1  per  cent  in  that  of  solution  II;  and  0.01  per  cent  in  the 
case  of  solution  III,  which  was  found  to  act  as  an  "ancestheticum  doloro- 
sum."  For  further  details,  Custer's  paper  should  be  consulted.  In  1901 
Schleich  (Deut.  Klinih,  1901,  parts  22  and  23)  recommended  exclu- 
sively one  of  the  three  infiltration  fluids  originally  formulated  by  him, 
namely,  the  normal  solution  II,  which  might,  according  to  the  require- 
ments of  the  case,  be  intensified  by  the  addition  of  tropacocain  or  weak- 
ened by  that  of  a  sterilized  0.2  per  cent  solution  of  sodium  chlorid.  In 
1906  Schleich  ("Schmerzlose  Operationen,"  5th  ed.;  Allg.  med.  Zen- 
tral-Ztg.,  1906,  JSTo.  48,  872)  reported  that  he  had  found  it  of  advantage, 
in  his  method  of  producing  anesthesia,  to  use  a  combination  of  cocain 
with  Alypin  (q.  v.),  since  a  greater  effect  was  obtained  in  this  manner. 
He  consequently  advised  the  substitution  for  the  older  solutions  of  the 
following : 

I  II  III 

Cocain  Hydrochloride 0.1  0.05        0.01 

Alypin 0.1  0.05        O.Oi 

Sodium  Chlorid 0.2  0.2  0.2 

Distilled  Water 100.0       100.0       100.0 

He  avoided  the  addition  of  adrenalin  for  fear  of  unpleasant  sec- 
ondary effects. 

Salolcamphor  (Salolum  Camphoratum) . — A  mixture  of  3  parts  of 
salol  and  2  parts  of  camphor.     A  local  antiseptic  and  anesthetic. 

Sanoform-Preparations. — Sanoform-cocainol-streupulver  contains  10 
per  cent  of  sanoform  (diiodosalicylic  acid  methyl  ester)  and  10  per  cent 
of  Ancesthesin  (q.  v.). 

Sanovagin. — See  Cocainol-Crenie. 

Sansom's  A.  C.  Mixture. — Alcohol,  1  part  by  volume;  and  chloroform, 
1  part  by  volume.  See  Med.  Times  and  Gaz.,  1870,  2,  107.  Sansom 
found  that  alcohol  "had  the  greatest  effect  in  sustaining  the  heart's  action 


810  ANESTHESIA 

during  the  influence  of  chloroform."  He  found  it  impossible  to  kill 
with  chloroform  a  frog  which  had  previously  inhaled  the  vapor  of  alco- 
hol. In  the  opinion  of  Sansom,  if  chloroform  is  to  be  used  without  an 
inhaling  apparatus,  in  order  to  insure  a  supposed  uniformity  of  strength 
of  vapor,  it,  should  be  mixed  with  alcohol,  or  with  alcohol  and  ethyl 
ether. 

Schafer  and  Scharlieb's  A.  C.  Mixture. — A  mixture  of  absolute  alco- 
hol, 1  part  by  volume,  and  chloroform,  9  parts  by  volume.  See  Trans. 
Roy.  Soc.  Ednh.,  Jfl,  part  ii,  No.  12. 

Schleich's  Anesthetics. — Owing  to  their  low  boiling  points,  these 
mixtures  are  said  to  be  rapidly  eliminated  from  the  system. 

(1)  Chloroform,  45  parts;  petroleum  ether  (  -f-  60°  C),  15  parts; 
ether,  180  parts;  boils  at  4"  38°  C.  (2)  Chloroform,  4  parts;  petroleum 
ether,  15  parts;  ether,  150  parts;  boils  at  +  40°  C.  (3)  Chloroform, 
30  parts;  petroleum  ether,  15  parts;  ether,  80  parts;  boils  at  -|-  42°  C. 

Mixture  1  is  used  in  short  operations,  while  2  and  3  are  for  major 
periods. 

For  a  full  discussion  of  Schleich's  Anesthetic  Mixtures,  see  Meyer: 
J.  Am.  Med.  Assn.,  Feb.  28,  1903 ;  and  Med.  Rec,  Aug.  15,  1908.  See 
Anesiliol.  Schleich's  narcotic  mixture  contains  2  parts  of  ethyl  chlorid, 
4  parts  of  chloroform,  and  12  parts  of  ethyl  ether.  It  is  said  to  sup- 
press local  pains  with  rapidity  and  certainty.  See  Schleich:  Therap. 
der  Gegenwart,  March,  1902.     Cf.  Sal  Ancestheticum  Schleichii. 

Scopolamin  Hydrobromid. — Scopolamin  hydrobromid  ( Scopolamina? 
hydrobromidum)  is  the  hydrobromid  (Ci,H2i]Sr04HBr.3H20)  of  an  al- 
kaloid obtained  from  plants  of  the  Solanacece ;  it  is  chemically  identical 
with  hyoscin  hydrobromid  U.  S.  P.  According  to  the  British  Pharma- 
copoeia, it  is  "the  hydrobromid  (C17H21NO4.HBr.3H2O)  of  an  alkaloid 
contained  in  hyoscyamus  leaves,  different  species  of  scopola,  and  possibly 
other  solanaceous  plants." 

Hyoscin  hydrobromid  was  introduced  in  the  United  States  Pharma- 
copoeia in  1890.  Hyoscin  (C17H21NO4)  is  found  in  the  leaves  and  seeds 
of  Hyoscyamus  niger,  Duboisia  myropoides,  Scopola  japonica,  Atropa  bel- 
ladonna, and  other  solanaceous  plants;  it  forms,  when  pure,  a  sirupy 
liquid.  The  hydrobromid  forms  colorless,  transparent,  rhombic  crystals, 
odorless,  possessing  an  acrid,  slightly  bitter  taste,  and  slightly  efflorescent. 
It  is  soluble  in  1.5  parts  of  water,  16  parts  of  alcohol,  and  in  750  parts  of 
chloroform  at  -|-  25°  C;  it  is  insoluble  in  ethyl  ether.  The  water  solu- 
tion shows  a  slightly  acid  reaction  to  blue  litmus  paper.  When  hyoscin 
hydrobromid  is  heated,  it  softens  at  about  -|-  100°  C;  it  first  fuses  and 
then  loses  its  water  of  crystallization  at  -|-  110°  C.  When  dried  over 
sulphuric  acid  until  it  is  completely  deprived  of  its  water  of  crystalliza- 
tion, it  melts  at  from  -\-  191°-192°  C.  When  ignited,  it  leaves  no  resi- 
due.    Schmidt  (Pharm.  Ztg.,  1891,  522)   considered  that  the  hyoscin 


A   LIST    OF    ANESTHETICS  811 

hydrobromid  of  commerce  was  essentially  seopolamin  hydrobromid,  and 
Hesse  {Ann.,  1893,  304)  confirmed  this  view.  The  United  States  Phar- 
macopoeia  introduced,  in  the  Eighth  Eevision,  Scopolaminse  hydrobromi- 
dum  production  as  a  separate  title,  but  referred  to  Hyoscina;  hydro- 
bromidum  for  the  description  and  tests ;  it  considered  them  to  be  identi- 
cal compounds. 

Schneiderlin  (Aerztl.  Mittheilg.  aus  und  f.  Baden,  1900,  No.  10)  rec- 
ommended operations  under  anesthesia  by  morphia-scopolamin,  which 
method  consisted  essentially  in  administering  to  the  patients  subcuta- 
neously,  1^2  to  2  hours  previous  to  the  operation,  seopolamin  and  morphia 
separately,  which  induce  deep  anesthesia.  Korff  {Munch,  med.  Woch., 
1901,  No.  29;  1902,  No.  27) ;  Bios  {Burns'  Beit.  z.  Tclin.  Chir.,  35,  No.  3, 
565)  ;  and  von  Steinbiichel  {Centralh.  f.  Gynakol.,  1902,  No.  48)  sup- 
plied most  favorable  reports  on  the  anesthesia  obtained  in  this  manner; 
but  Shicklberger  {Wien.  Min.  Woch.,  1902,  No.  51)  maintained  that  the 
morphia-scopolamin  method  was  adapted  only  for  those  cases  which 
rendered  a  general  anesthesia  absolutely  requisite  and  where  at  the  same 
time  chloroform  or  ether  were  contraindicated.  The  Schneiderlin-Korff 
method  of  anesthesia  by  morphia  and  seopolamin  is  based  upon  the  fact 
that  the  hypnotic  and  anesthetic  properties  of  morphia  and  seopolamin 
associate  themselves,  while  their  toxic  effects  on  the  respiration  and  cir- 
culation, being  antagonistic,  counterbalance  each  other. 

On  this  method  of  anesthesia,  see  the  following  additional  contribu- 
tions : 

Grevsen:   Miinch.  med.  Woch.,  1903,  No.  32,  1383. 

Bloch:   Hid.,  1903,  No.  26,  1135. 

Volkmann:  Deut.  med.  Woch.,  1903,  No.  51,  967. 

Heinatz:    Russkiy  chir.  Archiv,  1902,  No.  6. 

These  authors  appeared  to  be  satisfied  with  the  method;  in  fact,  the 
first  three  regarded  it  with  favor. 

Korff:   Miinch.  med.  Woch.,  1903,  No.  46,  2005. 

Stolz:    Wiener  Min.  Woch.,  1903,  No.  41. 

Stolz  ascribed  the  tranquil  nature  of  the  anesthesia  to  morphia  rather 
than  to  seopolamin,  and  considered  that  it  was  procurable  more  perfectly 
and  with  less  danger  by  an  injection  of  morphia  or  of  morphia-atropin 
before  the  administration  of  the  ordinary  anesthetic. 

Wild:   Berl.  Min.  Woch.,  1903,  No.  9,  188. 

Flatau:   Miinch.  med.  Woch.,  1903,  No.  28,  1198. 

These  two  authors  regarded  the  morphia-scopolamin  method  of  an- 
esthesia as  risky  and  cautioned  against  its  application. 

Hartog:  Ibid.,  1903,  No.  46,  2003. 

Hartog  found  that  the  combination  of  the  morphia-scopolamin  and 
ethyl-ether  methods  of  anesthesia  was  free  from  danger  and  thoroughly 
reliable.    See,  also,  Eobertson :    Sem.  med.,  1903,  No.  26,  220. 


812  ANESTHESIA 

Schneiderlin :    Munch,  med.  Woch.,,  1903,  No.  9,  371. 

Biimke :    Monats.  f.  Psych,  u.  Neurol.,  1903,  62. 

Koclimann :  Archives  internationalcs  de  pltarmacod.  et  de  tJierap., 
1903,  99. 

Liepelt:   Berl.  Uin.  ^Yoch.,  1901,  No.  15,  387. 

Eose:   Brit.  Med.  J.,  1903,  No.  2242,  1589. 

Korff:   Berl.  Idln.  Wocli.,  1904,  No.  33,  882. 

Wiesinger:    Deut.  med.  Wocli.,  1904,  No.  36,  1335. 

Wiesinger  considered  that  the  method  possessed  important  advantages 
and  certainly  appreciated  it. 

Bonheim:  Wiener  hlin.-therap.  Woch.,  1904,  No.  11,  329.  Bonheim 
recommended  the  combination  of  the  anesthesia  by  scopolamin  and  mor- 
phin  with  the  administration  of  chloroform.    Cf.  Korff:  loc.  cit. 

Landau:    Deut.  med.  ^Yoch.,  1905,  No.  28,  1108. 

Eys:    Csasopis  leharuv  ceslcy,  1905,  No.  18. 

Lasek:   Ibid.,  No.  2. 

Menod:    Presse  me^.^  1905,  No.  60. 

The  last  four  authors  recorded  failures  with  the  method. 

Kochmann:    Milnch.  med.  Woch.,  1905,  No.  17. 

Wartapetian:    Aerztl.  Rundschau,  1905,  No.  17,  202. 

According  to  these  two  authors,  the  method  unquestionably  possessed 
advantages,  yet  its  imj^rovement  was  necessary. 

Zahradnicky:    Wiener  med.  Ztg.,  1905,  No.  5,  65. 

Stein:   Deut.  med.  Ztg.,  1905,  No.  29,  313. 

Eoith:   Miinch.  med.  Woch.,  1905,  No.  46,  2213. 

Eotter :   Deut.  med.  Ztg.,  1905,  No.  2,  21. 

Wiesinger:    Deut.  med.  Woch.,  1905,  No.  38,  1525. 

Defontaine:     Sem.  med.,  1905,  No.  29,  345. 

Puschnig:    Wiener  hlin.  Woch.,  1905,  No.  16. 

Eies:   Ann.  of  Surg.,  Ji.2,  193. 

Stien:    Hospitalstidend^,  1904,  No.  43. 

Terrier  and  Desjardin :    Fresse  med.,  1905,  No.  18. 

Ziffer:    Monats.  f.  Gehurtshilfe  u.  Gyndlc,  1905,  No.  1. 

Seelig :    St.  Louis  Med.  Rev.,  Aug.  12,  1905. 

Eochard:    Merch's  Arch.,  1905,  No.  6,  187. 

Dirk:   Deut.  med.  Ztg.,  190b,  No.  2,  21. 

Weingarten :    Dissertation,  Giessen,  1904. 

The  last  twelve  mentioned  authors  recognized  the  value  of  the 
method. 

Gauss:   Miinch.  med.  Woch.,  1905,  No.  41,  1998. 

Kronig:    Hid.,  1905,  No.  52,  2536. 

Korff:   lUd.,  1905,  No.  52,  2539. 

Eoussy:    Revue  neural.,  1905,  644. 

Laurendeau:    Presse  med.,  1905,  No.  93,  749. 


A   LIST    OF    ANESTHETICS  813 

Cremer:  Textbook  on  "Painless  Confinements";  also  Welmans: 
Pharm.-Zig.,  1906,  No.  2,  17. 

Eoith  {loc.  cit.),  to  simplify  the  application  of  scopolamin,  recom- 
mended the  introduction  of  scopolamin  tablets;  but  Laurendeau  and 
Cremer  stated  their  emphatic  opposition  to  the  nsc  of  tablets  in  connec- 
tion with  subcutaneous  injections. 

Kionka:    Therap.  der  Gegenwart,  1908,  No.  8. 

Kreuter :   Milncli.  med.  Woch.,  1907,  No.  9. 

Bass:   Ibid.,  1907,  No.  11. 

Hocheisen:   Ibid.,  1907,  No.  11. 

Holzbach:   Ibid.,  1907,  No.  25. 

Kortf:   Bed.  Jclin.  Wocli.,  1906,  No.  51. 

Janson:    Psycli.-neurolog.  Woch.,  1907,  No.  25. 

Klein:   Zentr.  f.  Gyndhol.,  1907,  No.  27. 

Hirsch:    Wiener  klin.  Rundschau,  1907,  No.  52. 

Mansfeld:   Wiener  Jclin.  Woch.,  1908,  No.  1. 

Doucet:    Gaz.  med.  de  Nantes,  1907,  No.  2. 

Ebert:    The  Military  Surgeon,  May,  1907. 

StefEen:    Archiv  f.  Gynakol.,  1907,  No.  2. 

Cazin:    8em.  med.,  1907,  No.  42. 

Segelken:    Klin.  Monats.  f.  Augenheillc.,  1907,  75. 

Eochard:    Bull.  Gen.  de  Therap.,  1907,  No.  15. 

With  the  exception  of  Steffen  and  Eochard,  all  the  last  mentioned 
sixteen  authors  give,  as  a  result  of  their  experience,  a  favorable  opinion 
of  the  value  of  scopolamin  anesthesia.  It  may  therefore  be  assumed 
with  Kionka  that  failures  are  attributable  to  the  use  of  impure  prepara- 
tions, of  faulty  method,  or  of  applying  the  method  to  patients  who  are 
too  feeble.  Klein,  who  studied  scopolamin  sleep  and  spinal  anesthesia, 
by  themselves  and  in  combination,  in  gynecological  operations,  held  this 
view;  he  reported  that  scopolamin  anesthesia  in  combination  with 
spinal  anesthesia  was  especially  indicated  when  anesthesia  by  inhala- 
tion was  contraindicated. 

Bass  stated  that  "The  pain  of  delivery  was  considerably  reduced  in 
a  large  majority  of  the  cases  (he  made  observations  on  more  than  100 
confinements)  by  the  scopolamin-morphin  injections."  Kreuter  described 
the  value  of  scopolamin-morphin-chloroform  anesthesia  as  used  in  more 
than  100  operations. 

Baisch :    Berl.  Jclin.  Woch.,  1907,  No.  11. 

Moore:   La7icet,  1907,  No.  4364,  1084. 

Lindenstein:    Miinch.  med.  Woch.,  1908,  2064. 

The  experience  of  Lindenstein  extended  to  some  150  curgical  cases. 
He  recommended  the  use  of  solutions  Avhich  were  as  fresh  as  possible, 
and  he  ascribed  the  want  of  uniformity  of  action  to  individual  differ- 
ences. 


814  ANESTHESIA 

Caro :   Berl.  Tclin.  Wocli.,  1908,  246. 

Caro  advised  that  scopolamin-morphin  anesthesia  be  used  only  in 
persons  whose  heart  is  found  to  be  sound. 

Martin:    Wurttemherg.  nied.  Korrespond.,  1908,  No.  50. 

Boesch:  Zentralhl.  f.  GyndJcol,  1908,  No.  49. 

Hotz:  Deut.  med.  Woch.,  1908,  534. 

Gminder:   Beitr.  z.  Gehurts.  und  Gyndhol.,  1908,  No.  2. 

Kronig:    Deut.  med.  Wocli.,  1908,  No.  23. 

Mayer:    Zentr.  f.  Gynakol.,  1908,  No.  21. 

Keyserlingk:   Petersburger  med.  Wocli. ^  1908,  No.  21. 

Bruck:   Allg.  med.  Zentral-Ztg.,  1908,  No.  44. 

Kleinertz :   Zentralhl.  f.  Gynakol,  1908,  No.  42. 

Veit:    Therap.  Mojiatsh.,  1908,  1^0.  12. 

Zuntz:   Deut.  Aerzte-Ztg.,  1908,  No.  4. 

The  last  eight  mentioned  authors  published  communications  on  the 
production  of  scopolamin-morphin  partial  anesthesia  ('"Dammerschlaf") 
in  gynecological  practice;  they  were  almost  all  in  favor  of  the  method. 
Some  of  them  thought  that  its  use  should  be  limited  to  clinical  cases, 
while  Veit  thought  that  it  should  be  limited  to  urgent  cases  and  only 
used  in  neurasthenic  women.  Compare,  however,  the  extensive  experi- 
ence of  Kronig. 

Nicholson :  J.  Am.  Med.  Assn.,  1909,  No.  14. 

Nicholson  studied  the  harmful  effects  from  the  use  of  scopolamin. 
In  his  opinion,  no  fatal  case  had  been  described  in  the  literature  which 
could  be  definitely  proved  to  be  due  to  the  use  of  scopolamin.  Nichol- 
son employed  scopolamin  injections  in  650  cases,  and  found  their  excel- 
lent effect  and  their  well  known  advantages  fully  manifested  in  94  per 
cent  of  the  cases. 

Blisnianski:   Zentr.  f.  Gynakol.,  1909,  No.  9. 

Schoemaker:   Deut.  med.  Woch.,  1909,  No.  7. 

This  author  used  scopolamin-morphin-ether-chloroform  anesthesia  in 
3,000  cases,  being  well  satisfied  with  the  results;  no  by-effects  were  pro- 
duced on  the  patient. 

Trancu-Eainer :    Revista  sciintelor  medicale,  1909,  Nos.  5  and  6. 

Zadro:    Wiener  klin.  Wocli.,  1909,  No.  13. 

Berutti:   Med.  Klinik,  1909,  No.  14. 

Avarffi:    Gynakol.  Rundschau,  1909,  No.  9. 

Kroenig,  Gauss,  van  Hoosen,  Frogyesi,  and  Zweifel:  Munch,  med. 
Woch.,  1909,  No.  41. 

Stuelp:    Klin.  MonatsM.  f.  Augenheilk.,  1909,  No.  6. 

Beer:   Dissertation,  Freiburg  i.  Br.,  1910. 

Beer  enumerates  the  advantages  and  disadvantages  of  scopolamin- 
morphin  anesthesia.  This  dissertation  should  be  consulted  by  all  inter- 
ested in  scopolamin  anesthesia. 


A   LIST    OF    ANESTHETICS  815 

Einne:   Deut.  med.  Woch.,  1910,  No.  3,  110. 

Sick:  Ibid.,  1910,  No.  9,  406. 

Hatcher's  report  to  the  Council  of  Pharmacy  and  Chemistry  of  the 
American  Medical  Association  (J.  Am.  Med.  Assn.,  Feb.  5-12,  1910) 
is  probably  one  of  the  most  conservative  papers  written  on  this  subject. 
We  quote  from  this  paper: 

"Scopolamin  and  hyoscin  are  now  considered  interchangeable  words. 
Scopolamin  acts  similarly  to  atropin  in  large  doses,  but  in  small  doses  has 
a  different  action.  After  small  doses  th'ere  is  a  rise  of  blood-pressure 
but  little  change  in  the  pulse  rate.  Clinically,  it  produces  sleep  without 
analgesia,  if  used  alone.  It  is  excreted  by  the  kidneys.  When  used  in 
combination  with  morphin,  there  is  no  antagonism  in  regard  to  its  action 
on  the  respiration. 

"Statistics  give  us  over  thirty  lives  lost  in  an  unknown  number  of 
administrations.  These  deaths  have  not  occurred  so  frequently  of  late 
because  very  few  attempt  to  use  this  combination  without  any  other 
anesthetic.  All  insist  that  exceptional  cases  only  can  be  narcotized  with- 
out any  chloroform  or  ether.  When  this  occurs  we  are  on  dangerous 
ground.  Schneiderlin,  one  of  the  earliest  advocates  of  scopolamin  and 
morphin  in  narcosis,  recommends  as  high  as  1/25  grain  of  scopola- 
min and  IYq  grains  of  niorphm  in  a  space  of  li/4  hours. 

"Scopolamin  and  morphin  may  cause  death  from  paralysis  of  respira- 
tion. When  this  occurs,  artificial  respiration  is  usually  ineffective  and 
sometimes  useless.'"  Hatcher  states  that  no  deaths  had  been  recorded 
up  to  1910  in  which  the  dose  did  not  exceed  1/130  grain  of  scopolamin 
and  1/6  grain  of  morphin.  Ely  (N.  Y.  Med.  J.,  1906,  799)  reports  the 
death  of  a  patient  from  1/100  grain  of  scopolamin  and  %  grain  of 
morphin. 

Contraindications  to  this  form  of  medication  are  when  from  disease 
or  accident  the  respiratory  function  is  decreased,  also  in  all  cardiac  dis- 
eases and  other  conditions  which  interfere  with  the  circulation.  Graves' 
disease  also  contraindicates  its  use.  In  acute  or  subacute  nephritis  a 
very  rapid  heart  also  indicates  a  smaller  dose  of  hyoscin.  Grave  symp- 
toms sometimes  arising  after  the  operation  is  completed  are  probably 
some  of  the  causes  that  led  to  the  discontinuance  of  this  form  of  anes- 
thesia. H.  C.  Wood,  Jr.,  places  the  death  rate  at  one  in  two  hundred 
and  fifty;  Eoth  places  it  at  one  in  two  hundred  and  twenty-two;  an- 
other writer,  at  one  in  eighty. 

"Some  of  the  minor  after-effects,  when  used  in  large  doses,  are  in- 
tense thirst,  dryness  of  the  mouth  and  throat,  and  difficulty  in  swallow- 
ing. In  obstetrical  cases  1/200  grain  of  scopolamin  and  1/6  grain  of 
morphin  is  the  proper  medication  for  the  average  case.  The  princi- 
pal advantage  in  obstetrical  cases  is  that  the  memory  is  abolished,  the 
patient  being  often  surprised  when  told  that  it  is  all  over.     There  is 


816  ANESTHESIA 

often  entire  absence  of  pain,  or  this  factor  is  greatly  lessened.    The  prin- 
cipal objection  to  its  nse  is  on  account  of  the  danger  to  the  child.     Some 
are  born  asphyxiated,  or  die  asphyxiated  a  short  while  afterwards." 
The  conclusions  of  Hatcher  are  as  follows: 

(1)  An  attempt  to  use  scopolarain  and  morphin  alone  without  the 
addition  of  -some  other  drug  is  most  dangerous. 

(2)  There  is  no  possible  excuse  for  the  employment  of  ready-made 
mixtures  of  scopolamin  and  morphin.  They  should  be  prescribed  sep- 
arately as  indicated  by  the  patient's  condition. 

Otto:   Med.  Klinik,  1910,  No.  10,  380. 

Thomson:  Ednl.  Med.  J.,  Dec,  1909;  Beut.  Med.-Ztg.,  1910,  No. 
16,  276. 

Kiimmel:  Klin.  Monatsh.  f.  AugenheilJc,  1910,  No.  4;  Fortschr.  d. 
Med.,  1910,  No.  9. 

Collins:  J.  Obstet.  and  Gynacol.,  1910,  No.  6,  549;  J.  Am.  Med. 
Assn.,  1910,  1051. 

Kuckert:    Z.  f.  GehurtsUlfe  u.  Gyndlol.,  1910,  66,  No.  2. 

Faust:   Deut.  med.  WocJi.,  1910,  No.  11,  508. 

See  the  papers  by  Sick,  Otto,  Euckert,  Collins,  Thomson,  and  Kiim- 
mel for  the  value  of  scopolamin-morphin  in  inhalation  anesthesia. 

Kretz:   Med.  Klinilc,  1910,  No.  40,  1568. 

Bosse  and  Eliasberg:  Sammlung  hlin.  Vortrdge,  1910,  Nos.  599  to 
601;  Gyndkologie,  Nos.  215  to  217. 

Cremer:   Med.  Klinih,  1910,  No.  28,  1092. 

Salzberger:    Dissertation,  Freiburg  i.  Br.,  1910. 

Biirgi :   Korrespond.  f.  ScUweizer  Aerzte,  1909. 

Hauckold :   Z.  f.  exper.  Path.  u.  Therapie,  1910,  No.  7,  743. 

Briistlein :   Schweiz.  Korresp.-Bl.,  1910,  No.  26. 

Ewald:    Wiener  med.  Woch.,  1910,  1214. 

Luxardo:    Gazzetta  degli  ospedali  e  della  cliniclie,  June  9,  1910. 

Neu:   MilncJi.  med.  Woch.,  1910,  No.  36,  1873. 

Neu  made  experiments  to  learn  whether  nitrous  oxid  anesthesia 
might  not  be  improved  by  the  previous  use  of  scopolamin-morphin;  the 
results  obtained  by  experiments  on  animals  showed  that  this  was  in  fact 
the  case. 

Korff :  Med.  Klinik,  1911,  No.  2. 

Hastrup:    Ugeskrift  for  Lceger,  1911,  Nos.  1  and  2. 

Eood:  Brit  Med.  J.,  1911,  2,  652. 

Grigorjan:    Wratschehuaja  Gaceta,  1911,  No.  31. 

BTiistlem:   Zentr.  Chir.,  1911,  345. 

Eckert:    Ibid.,  1911,  857. 

Brant:    Russkiy  Wratsch,  1911,  No.  13. 

Neuber:   Z.  f.  drztl.  Fortbildung,  1911,  No.  12. 

Hippel:    FortschriLte  der  Med.,  1911,  229. 


A  LIST    OF   ANESTHETICS  817 

Bosse :  Berl.  Klinik,  1911,  No.  272 ;  Monats.  f.  Gehurtsh.  u.  Gyndlc, 
1911,  No.  3. 

Dietschky.   Korrespond.  f.  Schiv.  Aerzte,  1908,  No.  15. 

Klauber:   Milncli.  med.  Woch.,  1911,  No.  41,  2160. 

Gauss:    lUd.,  1911,  2355. 

Burkhardt:    MAincli.  med.  Woch.,  1911,  No.  15,  778. 

Hagemann:    Ihid.,  1911,  No.  28,  1427. 

Bjorkenheim :   Zentr.  Gyndlc. ,  1911,  No.  20,  759. 

On  the  value  of  scopolamin-morphin  in  midwifery,  see: 

Freeland-Solomons :    Brit.  Med.  J.,  1911,  i,  187. 

Strassmann:   Berl.  Jclin.  Woch.,  1911,  No.  23. 

Iljin:    BussTciy  Wratsch,  1911,  No.  12. 

Tichauer:     Dissertation,  Freiburg  i.  Br.,  1911. 

Corbett:  Brit.  Med.  J.,  1911,  1,  868. 

On  pantopon-scopolamin  anesthesia,  see: 
■    Hani:   Therap.  der  Gegenwart,, 1911,  No.  2. 

Desehwanden:   Korrespond.  f.  Schw.  Aerzte,  1911,  No.  4. 

Brunn:   Zentr.  Chir.,  1911,  No.  3. 

Briistlein:    7HJ.,  1911,  No.  10. 

Johannsen:   Zentr.  Gyndh.,  1911,  No.  19. 

Zeller:  Miinch.  med.  Woch.,  1911,  No.  25. 

Eekert:  Zentr.  Chir.,  1911,  No.  25. 

Fowelin:    7&t^.,  1911,  No.  27. 

Simon:   Miinch.  med.  Woch.,  1911,  No.  32. 

Kolde:    7&tU,  1911,  No.  28. 

Aulhorn:    ZHd,  1911,  No.  12. 

Haeberlin:    7&iU,  1911,  No.  33. 

Heinsius:    Berl.  Jclin.  Woch.,  1911,  No.  41. 

Gray:   Lancet,  Sept.  2,  1911. 

Scopomorphin. — Sterilized  euscopol-  (q.  v.)  morphin  solutions  are 
marketed  in  glass  tubes  of  1  and  2  c.  c.  capacity.  Each  c.  c.  contains 
0.0006  gm.  euscopol  and  0.015  gm.  morphin  hydrochlorid.  The  combina- 
tion is  used  for  the  production  of  total  and  semi-narcosis,  and  as  an  an- 
algesic and  sedative.  See  Neuber:  Z.  f.  drztl.  Forth.,  1911,  No.  12, 
.340;  Fonyo:  Ohste.  Aerzte.-Ztg.,  1910,  No.  2;  Korff:  Med.  Klinih, 
1911,  No.  2;  Salzberger:  Zentr.  f.  ges.  Therap.,  1910,  No.  10,  558;  and 
Meyer:  Miinch.  med.  Woch.,  1910,  No.  45,  2370. 

'        Septicylat. — This  contains  eugenol,  methyl  salicylate,  geranoil,  f or- 
;  maldehyd,  and  alcohol ;  it  is  used  in  dentistry. 

Sicherheitsbenzin. — A  mixture  of  1  volume  of  benzin  and  2  volumes 
of  Carbon  Tetrachlorid  (q.  v.). 

Sinecain. — Sinecain  is  a  3  per  cent  water  solution  of  quinin  hydro- 
chlorid, containing,  in  addition,  3  per  cent  of  antipyrin  and  0.05  mg.  of 
adrenalin,  intended  for  employment  as  a  local  anesthetic. 


818  ANESTHESIA 

See  E.  Schepelmann :  Med.  Klinik,  1913,  ISTo.  43. 

Skopomorphin. — See  Scopomorphin. 

Scemnoforme. — See  Somnoform. 

Soloid  "Hemisine"  Comp.  c.  Eucaino. — G.OOl  gm.  hemisin,  0.8  gm. 
sodium  chlorid,  and  0.2  gm.  Eucain  Ilydrochlorid  (q.  v.). 

Soluble  Hypodermic  Tablets  Novocain,  1/3  grain. — Each  tablet  con- 
tains Novocain  (q.  v.),  0.02  gm.  (1/3  grain). 

Soluble  Tablets  Novocain,  1  1/7  grains. — Each  tablet  contains  novo- 
cain, 0.074  gm.   (1   1/7  grains). 

Solution  Atoxyl,  10  per  cent,  with  Novocain,  1  per  cent  (sterilized). 
— Each  100  c.  c.  contaiji:  atoxyl,  10  gm. ;  and  novocain,  1  gm.  (each 
fluid  ounce  contains  atoxyl,  48  grains;  and  novocain,  4:^^  grains), 
dissolved  in  distilled  water. 

Somnoform. — This  anesthetic,  a  mixture  of  ethyl  chlorid,  83  parts; 
methyl  chlorid,  16  parts;  and  ethyl  bromid,  1  part  (60  of  ethyl  chlorid 
and  5  of  ethyl  bromid,  according  to  Gehes  Codex,  1911,  328),  is  made 
in  Bordeaux,  France.  In  1901  Eolland,  of  Bordeaux,  read  a  paper  on 
a  new  anesthetic  he  had  discovered  and  named  by  him  scemnoforme; 
this  was  a  mixture  of  ethyl  chlorid,  60  parts;  methyl  chlorid,  35  parts; 
and  ethyl  bromid,  5  parts  (see  Chem.  Centr.,  1903,  i,  188).  It  was 
marketed  by  a  London  and  by  a  Philadelphia  firm.  The  latter  firm 
later  came  under  the  control  of  a  JSTew  York  company,  but  retained,  as 
far  as  somnoform  was  concerned,  the  old  name.  Still  later,  after  the 
decomposition  of  somnoform  had  been  shown  to  be  due  largely  to  the 
ethyl  bromid  contained  therein,  this  compound  was  omitted  by  the  Lon- 
don firm  from  the  mixture  without  notification  being  given  to  the  Ameri- 
can company,  and  without  change  of  label.  The  United  States  Govern- 
ment detected  the  inconsistency  between  the  label  and  the  product.  Then 
the  American  firm  asserted  it  knew  nothing  of  it.  When  summoned 
by  the  Government,  the  firm  had  the  product  analyzed,  found  no  ethyl 
bromid,  pleaded  guilty,  and  had  a  fine  of  $25.00  imposed  (see  Judgment 
No.  571,  Food  and  Drugs  Act).  Then  the  present  formula  for  somno- 
form was  determined  upon.  It  may  be  said,  therefore,  that  somnoform, 
or  scemnoforme,  was  formerly  the  same  as  the  present  Narcoform 
(q.  v.),  but  at  present  is  a  mixture  of  ethyl  chlorid,  83  parts;  methyl 
chlorid,  16  parts;  and  ethyl  bromid,  1  part. 

Somnoform  was  recommended  by  Eolland  and  Eobinson  (Brit.  Med. 
J.,  1903,  No.  2215,  1408)  as  an  excellent  and  harmless  anesthetic  and 
narcotic,  since  it  acted  promptly,  and,  if  allowed  to  act  for  50  seconds 
to  2  minutes,  did  not  give  rise  to  undesirable  sequelae,  such  as  nausea 
and  vomiting.  Somnoform  has  been  employed  in  a  very  large  number 
of  cases,  especially  in  dentistry,  as  a  substitute  for  nitrous  oxid,  as  re- 
corded by  Gross:  Lancet,  1903,  No.  4156,  1169;  Secretan:  Ibid.,  1903, 
No.  4172, 1169;  Cole:  Presse  med.,  1903,  No.  63,  572;  Maguire:  Lancet, 


A   LIST    OF   ANESTHETICS  819 

1903,  No.  4174,  633 ;  Lankester :  Revue  de  Tlierap.,  1903,  No.  8,  272 ; 
Kirkpatrick:  Med.  Press  and  Circular,  April  22,  1903;  Gilmour:  The 
Dental  Rec,  1903,  496;  Eonnet:  Brit  Dental  J.,  1903,  215;  Galium: 
lUd.,  1903,  267;  and  Vierthaler:  Z.  f.  Stomatologie,  1903,  No.  11,  349. 
All  these  writers  concur  in  formulating  the  opinion  that  it  induces  com- 
plete relaxation  of  the  muscles  without  cyanosis,  and  they  state  that  the 
patients  nearly  always  return  to  consciousness  with  a  smiling  coun- 
tenance; but,  to  quote  Merck:  Ann.  Rep.,  11,  168)  :  "It  is,  however,  in 
its  application  in  small  operations  that  its  utility  will  probably  be  great- 
est.'^ Eolland  devised  a  special  mask  for  the  administration  of  somno- 
form. 

On  the  physiological  action  of  somnoform,  see  Cole:  Brit.  Med.  J., 
June  20,  1903,  1421;  and  Webster:  Bio-Chemical  J.,  1906,  1,  328. 

Stenocarpin. — An  alkaloid  from  the  leaves  of  the  "tear  blanket"  tree 
of  Louisiana;  said  by  Claiborne  (*S'ct.  Am.  Suppl.,  No.  608)  to  possess 
local  anesthetic  properties. 

On  the  application  of  stenocarpin  as  a  local  anesthetic,  consult  the 
following  literature : 

Claiborne:  "A  New  Local  Anesthetic,"  N.  Y.  Med.  Rec,  July  30 
and  Oct.  1,  1887. 

Goodmann :    "Stenocarpin,"  Med.  Rec,  July  30,  1887. 

Jackson:  "Observations  on  the  Action  of  Stenocarpin,  the  New 
Local  Anesthetic  and  Mydriatic,"  Am.  Med.  News,  1887,  255. 

Knapp :    "Experiments  with  Stenocarpin,"  Med.  Rec,  1887,  180. 

Morse:  "Gleditschine  (Stenocarpin),"  Phila.  Med.  Surg.  Rept.,  1887, 
701. 

Novy:    "What  Is  Stenocarpin?"  Am.  pharm.  Rund.,  1887,  248. 

Stephen's  Mixture. — An  anesthetic  mixture  containing  chloroform 
and  alcohol,  da;  and  Cologne  Water,  q.  s.  (Miiller:  "Narkologie,"  1, 
493). 

Stovain  or  Stovaine  (Benzoyl-Ethyl-Dimethylaminopropanol  Hydro- 
chlorid. — Stovain  is  2-benzoxy-2-methyl-l-dimethyl-amino  butane  hy- 
drochlorid,  CH3.CH2C(CeH5C00)  (CH3)CH.N(CH3)2.HC1  =  C^.H^,- 
OgNCl.  It  is  closely  related  to  Alypin  (which  see)  ;  it  was  produced 
synthetically  by  Fourneau  (hence  its  name)  in  1904,  and  was  first  used 
in  subarachnoid  analgesia  by  Chaput. 

Stovain  is  prepared  by  causing  a  reaction  of  benzoyl  chlorid  on  the 
a-dimethyl-amino-pentonal-5,  which  is  itself  the  product  of  reaction  of 
ethylmagnesium  chlorid  on  methylaminoacetone.  It  crystallizes  in 
small,  brilliant  scales,  which  melt  at  +175°  C.  (347°  F.).  It  is  ex- 
tremely soluble  in  water  and  easily  in  methyl  alcohol  and  acetic  ether, 
but  requires  5  parts  of  absolute  ethyl  alcohol  for  solution  and  is  only 
slightly  soluble  in  acetone.  It  is  quite  stable  and  its  solutions  may  be 
sterilized  at  -|-  115°  C.  (239°  F.)  without  suffering  decomposition.    The 


820  ANESTHESIA 

water  solution  is  slightly  acid  to  litmus,  but  is  neutral  to  methyl  orange. 
It  is  precipitated  by  all  the  alkaloidal  reagents  and  is  decomposed  by  even 
very  dilute  alkalies.  It  is  incompatible  with  alkalies  and  all  alkaloidal 
reagents. 

Actions  Mild  Uses. — Stovain  acts  as  a  local  anesthetic.  It  has  about 
the  same  power  as  cocain,  but  dilates  the  blood  vessels,  whereas  cocain 
contracts  them.  It  is  only  one-third  to  one-half  as  toxic  as  cocain. 
Stovain  is  also  said  to  exert  a  tonic  action  on  the  heart. 

It  is  used  as  a  local  anesthetic;  while  most  reports  are  favorable,  one 
case  of  gangrene  has  been  reported  following  the  use  of  a  10  per  cent 
solution.  On  the  physiological  properties  of  the  methyl-,  amyl-,  phenyl-, 
and  benzyl-homologues  of  stovain,  see  Veley  and  Synies :  Chem.  News, 
103,  92,  Fourneau  has  more  recently  prepared  a  new  compound,  the 
propyl  ester  of  dimethyl-amino-oxy-benzoyl-isobutyric  acid,  which  pos- 
sesses pronounced  local  anesthetic  properties;  it  abolishes  the  contrac- 
tility of  muscle  less  rapidly  than  does  stovain  or  methyl-stovain,  and 
has  also  less  effect  on  blood  pressure  and  on  respiration. 

Dosage. — Internally,  0.002  gm.  (1/30  grain),  pill  form.  Locally  it 
may  be  used  in  the  eye  in  4  per  cent  solution  and  applied  to  other  mu- 
cous membranes,  as  in  laryngology,  in  from  5  to  10  per  cent  solution. 
For  hypodermic  injections  for  local  anesthesia,  it  can  be  used  in  0.75  to 
1  per  cent  solution. 

For  further  information  on  stovain,  consult  the  following  contribu- 
tions : 

Adam,  C. :    Milnch.  med.  Woch.,  1906,  No.  8. 

Alessandri:  "Eachistovainisation,"  Congres  de  Chir.  de  Paris,  Oct., 
1906. 

D' Almeida:  "La  Stova'ine  comme  anesthesique,"  Acad.  Nacional  de 
Med.,  Eio  de  Janeiro,  May  11,  1905. 

Andhelovici- Joanitescu :  "Das  Stovaine  als  intrarachidianes  Anal- 
gesikum  in  der  Yenerologie,"  Romania  med.,  No.  22,  1905 ;  abstracted  in 
Milnch.  med.  Wocli.,  1906,  I^o.  13. 

Arnezzi:   Brit.  Med.  J.,  1905,  No.  2320,  92. 

Audbert,  A. :  "La  rachistovainisation  en  obstetrique,"  These  de 
Paris,  Apr.  4,  1906.  i 

Babcock,  W.  W. :  "Spinal  Anesthesia  with  Special  Eeference  to  the 
Use  of  Stovaine,"  Therap.  Gaz.,  30,  239,  Apr.  15,  1906.  "Spinal  Anes- 
thesia; a  Clinical  Study  of  658  Administrations,"  paper  read  before  the 
Section  on  Surgery — Medical  Society  of  the  State  of  Penn.,  Cambridge 
Springs,  Sept.  14-17,  1908.  (Printed  in  Penn.  Med.  J.,  Aug.,  1909.) 
The  Obstetrical  Society  of  Philadelphia — Meeting  Thursday,  March  4, 
1909.  Barton  Cooke  Hirst :  "A  Note  on  Sacral  Anesthesia" ;  "A  Study 
of  a  Case  of  Spondylolisthesis."    W.  Wayne  Babcock :    Discussion. 

Badini:     L'Ospedale  maggiore,  1907,  261. 


A  LIST   OF   ANESTHETICS  821 

Bardescu:    "La  stova'me  en  chirurgie,"  Spitalul/ 1904:,  Ko.  23. 

Barker,  A,  E. :  "A  Case  ef  Embolus  Blocking  the  Bifurcation  of  the 
Aorta,  Gangrene  of  One  Leg.  Amputation  under  Lumbar  Analgesia/' 
London  Clin.  J.,  28,  No.  4  (May  9,  1906). 

Barker,  A.  E. :  "A  Report  on  Clinical  Experiences  with  Spinal  An- 
algesia in  100  Cases,"  Brit.  Med.  J.,  March  23,  1907. 

Baylac,  M.  J. :  "Note  sur  la  toxicite  comparee  de  la  stovaine  et  de 
la  cocaine,"  Soc.  de  Biol.,  Paris,  Feb.  3,  1906  (Revue  Internat.  de  Med., 
1906,  No.  4). 

Becker:  "Operationen  mit,  Riickenmarksanasthesie,"  Miincli.  med. 
WocJi.,  1906,  No.  28,  1344. 

Bell,  E.  E. :  "Stovaine,  a  New  Local  Anesthetic,"  N.  Y.  Amer.  Vet. 
Rev.,  Jan.,  1905,  28,  No.  10. 

Benitez  Fco,  Cabrera :  "La  Stovaina,"  Rev.  de  la  Escuela  de  Med.  de 
la  Hahana,  1906,  5,  No.  3. 

Beurmann  (de)  and  Tanon:  "Emploi  de  la  stovaine  en  dermatol- 
ogie,"  Bull.  Soc.  Frang.  de  Dermatol.,  1904,  No.  9. 

Bier:  "Ueber  den  jetzigen  Stand  der  Eiickenmarksanaesthesie,  ihre 
Berechtigung,  ihre  Vorteile  und  Nachteile  gegeniiber  anderer  Anaes- 
thesierungs  Methoden,"  34  Kongress  der  deutschen  Gesellsch.  fiir  Chir- 
urgie, sApr.,  1905.  (Eef.  Miinchen.  med.  Wchnschr.,  1905,  No.  23, 
1117.) 

Billon,  F. :  "Sur  un  medicament  nouveau,  le  chlorhydrate  d'amy- 
leine,"  Acad,  de  Med.  de  Paris,  March  29,  1904. 

Blondeau:     "Sur  I'emploi  de  la  stovaine  adrenalisee,"  J.  de  Med.  d. 
Chir.  pract.,  76,  No.  16,  Aug.  25,  1905 ;  Therap.  Neuheiten,  1906,  No.  1. 

Boeckel :  Deut.  m,ed.  Woch.,  1906,  1724. 

Bonachi :  "Vingt.-trois  cas  de  rachistovainisation,"  Bull,  et  Mem.  d. 
la  Soc.  de'Chirurg.  d.  Bucharest,  8,  68. 

Bradburne:  "Affections  of  the  Eye  (Stovaine),"  London,  Treatment, 
March,  1906. 

Braun:  "Ueber  Medullaranaesthesie,"  Munch,  med.  Woch.,  1905, 
1335;  "Ueber  einige  neue  ortliche  Anasthetica,"  ibid.,  1667;  "Die 
Leistungen  und  Grenzen  der  lokal  Anasthesie,"  Deut.  med.  Wocli.,  1906, 
42,  1668. 

Bruni,  C. :  "II  metodo  Cathelin  nella  cura  dell  incontinenza  essen- 
ziale  dorina,"  Ac.  d.  med.  chir.,  Naples,  1905. 

Bruno,  D. :  "La  Stovaina  in  Terapia  oculare,"  Rev.  internaz.  de 
Clinica  e  Terapia,  Naples,  1,  No.  4. 

Busse :  "Ueber  die  Verbindung  von  Morphium-Skopolamin  Injek- 
tionen  mit  Eiickenmarksanasthesie  bei  gynakologischen  Operationen," 
MUnch.  med.  Woch.,  1906,  1858. 

Cavazzani  and  Balao  Venturo:  "Su  alcune  nueve  maniere  di  anes- 
tesia  generale  e  locale,"  Rev.  veneta  di  sc.  med.,  1905,  25,  No.  1.    "Con- 


822  ANESTHESIA 

tribute  alia  anestesia  lombare  e  generale  con  la  Stovaina  e  la  Scopola- 
mina,"  ibid.,  1906,  S3,  No.  7. 

Cernezzi:  "L' Anestesia  locale  con  la  stovaina  e  con  la  miscela  sto- 
vaino-adrenalinica  nella  chirurgia  generale/'  Riforma  medica.  Mar.  11, 
1905. 

Chaput:  "La  stovaine,  anesthesique  local.  Valeur  de  la  stovai'ne 
comparee  a  la  cocaine,"  Bull.  Soc.  hiol..  May  12,  1904.  "L' Anesthesia 
rachidienne  a  la  stovaine,"  Archives  de  Tlierap.,  Nov.  15,  1904.  "Anes- 
thesie  lombaire  a  la  stovaine,"  ihid.,  April  1,  1905.  "D'anesthesie  totale 
au  moyen  de  la  rachi-stovainisation,"  Bull.  Soc.  hiol.,  July  6,  1907; 
Presse  med.,  1907,  131.  "De  la  rachistovainisation,"  Soc.  de  chir.,  seance 
du  4  mars  1908 ;  cf .  Bull.  Soc.  chir.,  1904,  No.  30. 

Chartier :  "La  rachistovainisation  en  obstetrique,"  La  Gynecol.,  Oct. 
3,  1904. 

Chevalier  and  Scrini:  "Sur  Faction  pharmacodynamique  et  clinique 
de  la  novocaine,"  Paris,  Soc.  d.  Therap.,  July  27,  1906. 

Chiene,  George :  "The  Use  of  Stovaine  as  a  Spinal  and  Local  Anes- 
thetic," Scot.  Med.  Surg.  J.,  1906,  No.  3. 

Christie,  W.  W. :  "The  IJse  of  Stovaine  as  a  Local  Anesthetic  in 
Throat  and  Nose  Operations,"  Glasgow  Med.  J.,  Feb.,  1906. 

Cisler,  Jos. :  "Nova  anaesthetika  vrhino  laryngologie,"  Csasopsis 
lekaruv  cesJcy,  Prague,  Jan.  3,  1906. 

Coakley,  C.  G. :  "Eeport  on  the  Use  of  Stovaine,"  N.  Y.  Acad. 
Med.,  Feb.  22,  1905 ;  Zahntechn.  Reform.,  1906,  No.  3. 

Coderque :   Rev.  de  med.  y  dr.,  Sept.  7,  1907. 

Cohn:  "Medullaranasthesie  in  der  Geburtshilfe,"  Mediz.  Gesell.  in 
Giessen,  Jan.  30,  1906 ;  Deut.  med.  Woch.,  1906,  22. 

Couteaud:    Bull.  d.  I'Acad.  d.  Med.,  1908,  No.  26. 

Czermak :  "Nouvelles  observations  demontrant  I'inocuite  de  la  rachi- 
stovainisation pour  les  reins,"  Zentralbl.  f.  Chir.,  Feb.  15,  1908. 

Czerny :   3J/.  Kongress  der  Deut.  Gesellsch.  f.  Chir.,  Apr.,  1905. 

Dean,  H.  P. :  "The  Importance  of  Anesthesia  by  Lumbar  Injec- 
tions in  Operations  for  Acute  Abdominal  Disease,"  Brit.  Med.  J.,  1906, 
No.  2367. 

Demaillasson :  "Les  injections  analgesiantes  'loco  dolenti'  dans  les 
nevralgies  peripheriques,"  These  de  Paris,  1905. 

Deetz:  "Erfahrungen  ueber  360  Elickenmarksanasthesien  mit  Dem- 
onstrationen,"  Munch,  med.  Woch.,  1906,  No.  28;  Z.  f.  Kranhenpf., 
1906,  No.  3. 

.  Delattre,  G. :  "Accidents  consecutif s  a  I'introduction  des  substances 
medicamenteuses  dans  le  liquide  cephalorachidien,"  These  de  Paris, 
1905. 

Deupes,  E. :  "La  stovaine :  etude  expef imentale  et  clinique,"  These 
de  Toulouse,  1906. 


A   LIST    OF    ANESTHETICS  823 

Dion,  Gr. :  "Stovaine;  son  cmploi  en  chimrgie  oculaire/'  jf7ie.se  de 
Bordeaux,  1905. 

Doleris :  "La  stovaine,"  Soc.  d'Ohstetriq.,  de  Gynec.  et  de  Fediair., 
Paris,  July  11,  1904. 

Doleris  and  Chartier :  "La  raehistovainisation  en  gynecologic,"  La 
Gynecol.,  Feb.,  1905. 

Donitz:  "Technik,  Wirkung  u.  specielle  Indication  der  Eiicken- 
marksantisthesie,"  Arch.  f.  Jdinisch.  Chir.,  1906,  77,  No.  4. 

Donitz:  "Wie  vermeidet  man  Misserfolge  bie  der  Lumbalaniisthe- 
sie,"  Munch,  med.  Woch.,  1906,  1339. 

Dubar :  "La  stovaine  en  oto-rhino-laryngologie,"  Progres  med.,  Nov. 
26,  1904;  Rev.  de  Therap.,  1905,  57,  No.  2. 

DufPour :  "Etude  sur  la  sterilisation  et  I'emploi  des  solutions  hypo- 
dermiques,"  Toulouse,  July,  1905,  These. 

Elting,  A.  W. :  "The  Method  and  Indications  for  the  Use  of  Spinal 
Anaesthesia,"  Albany  Med.  Ann.,  May,  1906. 

Eeliziani:  "Sull'anestesia  rachistovainica,"  Policlinico,  1908,  sez. 
j)rat.,  fasc.  7. 

Fernandez,  J.  S. :  "Le  estovaina  en  nuestra  oftamologica,"  Cro- 
nica  med.-quir.  de  la  Hahana,  May,  1905. 

Finckelnburg :  "Neurologische  Beobachtungen  und  Untersuchungen 
bei  der  Eiickenmarksanasthesie  mittelst  Kokain  und  Stovain,"  Miinch. 
med.Woch.,  1906,  No.  9,  397. 

Fischer,  E. :  "Ueber  Stovaine  in  der  oto-rhino-laryngologischen 
Praxis,"  Deut.  med.  Ztg.,  1906,  No.  38. 

Foisy:  "La  stovaine,  ses  advantages,  ses  inconvenients,  son  incom- 
patibilite  avec  I'adrenaline,"  Tribune  med.,  1904,  No.  37. 

Forns:  "La  estovaina  in  obstetrica,"  Rev.  d.  I.  especialidades  med., 
Madrid,  Sept.  20,  1904. 

Fourneau,  E. :  "Sur  les  amino-alcools  tertiares,"  Acad.  d.  Sci.,  Paris, 
Feb.,  1904;  "Anesthesiques  locaux,"  Rev.  gen.  d.  Sci.,  Sept.  30,  1904; 
Bull.  Sci.  Pharmacol.,  1904,  No.  9. 

Fourneau,  C. :  "Un  nouvel  anesthesique  local.  La  stovaine,"  J. 
Pharm.  Chim.,  Aug.  1,  1904. 

Freund:  "Weitere  Erfahrungen  mit  der  Eiickenmarksnarkose," 
Miinch.  med.  Woch.,  1906,  1109. 

Fromaget  and  Dion:  "Action  mydriatique  de  la  stovaine,"  Presse 
med.,  Oct.  1,  1904. 

Galceran,  A.  B. :  "La  estovaina  como  anestesico  y  analgesico,"  Bar- 
celona, Archives  d.  Therap.,  1905,  No.  11. 

Galletta:  "Contribuzione  clinica  alia  rachistovainizzazione,"  Poli- 
clinico, 1908,  sez  chir.,  fasc.  1  and  2. 

Garcia  Tapia :  "La  stovaine ;  Sus  applicaciones  in  oto-rinilarin- 
gologia,"  Bolet.  di  laringol.,  Madrid,  Nov.  3,  1904. 


824  ANESTHESIA 

Gaudier :  "De  la  rachi-stovainisation  chez  les  enf ants,"  Soc.  de  Chir., 
seance  du  16  Janvier,  1907. 

Gaviss:  "Die  JSTarkose  in  der  operativen  Geburtshiilfe,"  Tlierap.  der 
Gegenwart,  1906,  453. 

Gemnseus:    "Das  Stovain,''  Dissert.,  Bern,  1905. 

Gironi :  "Contribution  clinique  a  la  rachistovainisation,"  Gaz.  degli 
ospedali,  July  7,  1907. 

Goldscheider :    Tlierap.  der  Gegejiwart,  1905,  No.  12. 

Greiffenhagen :    ZentralU.  f.  Cliir.,  1906,  No.  19. 

Hackenbruch :  "Lumbalanasthesie,"  Wiesbaden  Centralbl.  f,  CJiir., 
1906,  No.  14. 

Halbron  and  Chartier:  "Note  sur  la  reaction  meningee  apres  la 
rachistovainisation,"  Paris,  Feb.,  1905. 

Heinecke  and  Lowen :  "Lumbalanasthesie  niit  Stovaine  und  Novo- 
cain," Brunssclie  Beit.  z.  Id.  Chir.,  Leipzig,  1906,  50,  Part  2. 

Hermes:  "Eiikenmarksanasthesie,"  34th  Deut.  Chir.  Kongress  in 
Berl.,  Apr.,  1905 ;  "Weitere  Erfahrungen  iiber  Eiickenmarks-anasthesie 
mit  Stovaine  und  Novocain,"  Med.  Klinilc,  1906,  No.  13. 

Hildebrandt:  "Die  Lumbalanasthesie,"  Berl.  Tclin.  Woch.,  Aug.  31, 
1905. 

Holzbach:  "80  Lumbalranasthesien  ohne  Versager,"  Milncli.  med. 
Woch.,  Jan.  22,  1908. 

Hosemann:  "L'Inocuite  pour  le  rein  de  la  rachi-stovainisation," 
ZentralU.  f.  CUrurg.,  Jan.  10,  1908. 

Huchard:  "Quelques  Faits  therapeutiques  sur  la  stovaine,"  Acad,  de 
Med.,  Paris,  July  12,  1904;  J.  des  Practiciens,  1904,  33. 

Impallomeni,  G. :  "Le  iniezoni  intramuscolare  di  salicilato  sodico  e 
stovaina.  Loro  applicazioni  therapeutiche,"  II  Policlinico,  May  6,  1906, 
13,  No.  18. 

Jonnesco :  "Sur  la  rachistovainisation,"  Bull,  et  Mem.  de  la  Soc.  de 
Chir.  de  Bucharest,  8,  60-63;  "Eemarks  on  General  Spinal  Analgesia" 
(letter  to  the  editor),  N.  Y.  Med.  J.,  Jan.  1,  1910;  "Eemarks  on  Gen- 
eral Spinal  Analgesia,"  Brit.  Med.  J.,  Nov.  13,  1909  (Abstr.  N.  Y.  Med. 
J.,  Dec.  4,  1909,  1133)  ;  "General  Eachiansesthesia,"  Med.  Times 
(N.  Y.),  Feb.,  1910;  "Concerning  General  Eachianaesthesia,"  Am.  J. 
Surg.,  Feb.,  1910. 

Joris,  L. :  "La  stovaine,"  Bollet.  dell.  Assoc,  medica.  Tridentina, 
Jan.  1,  1906. 

Kamenzave,  L. :  "La  Stovaine,  etude  experimentale,"  These  de 
Geneve,  1905. 

Kendirdjy,  L. :  "L'Anesthesie  chirurgicale  par  la  stovaine,"  Paris ; 
Masson  et  C,  edit.  1906.  "General  Indications  for  and  Technique  of  Lo- 
cal Ansesthesia,"  J.  d.  Med.  et  d.  Chir.  Pratiques,  Apr.  10,  1909,  80,  No. 
7. 


A   LIST    OF    ANESTHETICS  825 

Kendirdjy  and  Bertreaux,  E. :  "L'Anesthesie  chirurgicale  par  in- 
jection sousarachinoidienne  de  stovaine,"  Fresse  med.,  1904,  6G0. 

Kendirdjy  and  Burgaud,  V. :  "Cent  quarante  nouveaux  eas  de 
rachistovainisation,"  ibid.,  M^sij  31,  1905;  Allg.  m,ed.  Zentral.-Zig., 
1905,  No.  24. 

Koenig,  C.  J.:  "L' Analgesic  locale  par  le  stovaine,"  Arch.  Intern, 
de  Laryngol.,  1905,  18,  5,  9. 

Krecke:    Munch,  med.  Woch.,  1906,  No.  6. 

Kroemer:  "Beckenerweiternde  Operationen,"  Mediz.  Gesell.  in 
Giessen,  Jan.  30,  1906;  Deut.  med.  Woch.,  1906,  900. 

Kroner :  "Ueber  einige  neuere  Arbeiten  zur  Lumbalpunktion  iind 
Lumbalanasthesie/'  Therap.  der  Gegenwart,  1906,  361. 

Kroenig,  M. :  "Denx  cents  cas  de  narcose  mixte  par  combinaison 
de  la  scopalamine-morphine  avec  la  rachistovainisation,"  Presse  med., 
Apr.  14,  1906. 

Kroenig  and  Gauss:  "Observations  anatoiniques  et  physiologiques 
au  cours  d'un  premier  millier  de  rachi-anasthesies,"  Miinch.  med.  Woch.,. 
Oct.  1  and  7,  1907,. 

Kugel,  L. :  "Stovaine  ein  neues  Anasthetikum,"  Wien.  Jclin.  therap. 
Woch.,  1906,  No.  7. 

Kiimmel:  "Stovainlumbalanasthezien,"  Deut.  med.  Woch.,  1906, 
126. 

Lacceti,  C. :  "A  proposito  dell'anestesia  locale  stovainica  in  chirur- 
gia,"  Gaz.  internaz.  di  m,edic.,  July,  1906. 

Laewen:    Beitr.  zur  Min.  Chir.,  1906,  2,  50. 

Lang:     Deut.  med  Foc/i.,  1906,  No.  35. 

Lasio:  "La  rachistovainisation  en  chirurgie  urinaire,"  Clin.  Chir., 
1907,  fasc.  9. 

Lapersonne,  F.  de:  "Un  nouvel  anesthesique  local,  la  stovaine," 
Presse  med.,  1904,  No.  30,  233. 

Launoy,  L. :  "Action  du  chlorhydrate  d'amyleine  sur  le  mouvement 
ciliare/'  Acad,  des  Sciences,  Paris,  July  11,  1904. 

Launoy  and  Billon:  "Sur  la  toxicite  du  chlorhydrate  d'amyleine," 
Acad,  des  Sciences,  Paris,  15  May,  1904;  Compt.  rend.,  March  15  and 
July  11,  1904;  Presse  med.,  1904,  368. 

Lazarus,  .P. :  "Zur  Lumbalanasthesie,"  Berl.  Min.  Woch.,  Mar.  19, 
1906. 

Lepnender :  "Sur  I'anesthesie  locale  et  la  sensibilite  du  corps  et  des 
tisms," -Oentralh.  f.  C/wV., .1906,  No.  9. 

Loeser:    Deut.  med.  Woch.,  1906,  483. 

Loffler:  "Lumbalanasthesie  mit  Stovaine,"  Franhfort-Mi'mch.  med. 
Woch.,  1906,  95. 

,    LohmanUj    W. :      "Das    Stovaine    in    der    Infiltration- Anasthesie," 
Fortschr.  k  Mediz.,  Nov.  20,  1905,  No.  33. 


826  ANESTHESIA 

Lohrer:  "Zur  Behandlimg  hysterischer  Kontrakturen  der  unteren 
Extremitaten  durch  Lumbalanasthesie,"  Munch,  med.  Woch.,  1906,  1568. 

Lucangelli,  G.  L. :    "La  Stovaine  I'Alipina,"  Gaz.  med.,  Dec,  1905. 

Luke,  T.  D. :  "Stovaine  :  a  Synthetic  Analgesic,"  Scot.  Med.  Assn.  J., 
Edinburgh,,  1905, 17, 143. 

McGavin :  "A  Eeport  of  250  Cases  of  Spmal  Analgesia  by  the  Use 
of  Stovaiue-Glucose  Solution,"  The  Practitioner,  Aug.,  1909. 

McKenzie,  D. :  "The  Local  Anaesthetic  Action  of  Stovaine,"  Brit. 
Med.  J.,  1906,  Ko.  2367. 

Marchetti,  L. :  "La  stovaina  como  anestetico  locale  nella  practica 
chirurgia,"  Gaz.  degli  osped.  e.  del.  din.,  ISTov.  26,  1905. 

Martin,  Collier  F. :  "The  Use  of  Spinal  Anesthesia  in  Rectal  Sur- 
gery," The  Proctologist,  Sept.,  1909. 

Mercier,  0.  F. :  "L'Anesthesie  chirurgicale  par  la  stovaine,"  Mon- 
treal, L'Union  med.  du  Canada,  May  1,  1906,  35,  No.  5. 

Meyer,  A. :  "Zwei  neue  Lokalanasthetica  in  der  rhinolaryngolo- 
gischen  Praxis,"  Therap.  Monats.,  1905,  No.  5,  240. 

Milko:  "Spinalanalgesie  mit  Stovaine,"  Deut.  med.  Woch.,  1906, 
1400. 

Mosetig:    "La  stovaine,"  Deut.  Naturforsch.  Versammlung,  1905. 

Miiller,  Benno :  "Stovaine  als  Anasthetikum,"  Sammlung  Jclin.  Vor- 
trdge,  1906,  15,  No.  428,  No.  8,  495. 

Narewski :    Zahndrztliche  Rundschau,  1907,  No.  19. 

Nogue,  E. :  "La  stovaine  en  stomatologie,"  Arch,  de  Stomatolog., 
1904,  Nos.  4  and  5. 

Noland,  Lloyd:  "Stovaine  Spinal  Angesthesia,  a  Report  of  Twenty 
Cases,"  Ann.  of  Surg.,  Apr.,  1910. 

Nigoul,  M. :  "Constatations  cliniques  au  sujet  de  la  stovaine,"  Con- 
cours  medicale,  Paris,  June  24,  1905. 

Ostwald,  T. :    Berl.  klin.  Woch.,  1906,  No.  1.  " 

Pauchet,  Amiens:  "La  chirurgie  rurales;  rachistovainisation,"  La 
Clinique,  1906,  633.  "Petite  chirurgie;  traitement  du  panaris,"  La 
Clinique,  1906,  681. 

Penkert:  "Lumbalanasthesie  im  Morphium-Skopolamin  Dammer- 
schlaf,"  MUnch.  med.  Woch.,  1906,  646 ;  1907,  No.  25. 

Perez :     II  Policlinico,  1907,  No.  3. 

Piedallu,  R. :    "La  stovaine,"  These  de  Paris,  July,  1905. 

Piga,  A. :  "Contribucion  al  estudio  de  los  efectos  fisiologicos  y  tera- 
peuticos  de  la  estovaina,"  Madrid,  Los  nuevos  remedios,  Apr.  30  and 
May  30, 1905. 

Pochhammer :  "Zur  Teknik  und  Indikationstellung  der  Spinal-anal- 
gesie,"  Deut.  med.  Woch.,  1906,  No.  24. 

Poenaru  Caplescu :  "Rachistovaiue,"  Spitalul,  1905,  19-20  j  "La  sto- 
vaine en  chirurgie,"  ihid.,  1904,  21-22. 


A   LIST    OF   ANESTHETICS  827 

Poenaru:    Deut.  med.  Wocli.,  1910,  No.  8. 

Poinsot,  A. :    "La  cocaine  en  art  dentaire/'  These  de  Paris,  1905. 

Pont,  A,:  "A  propos  d'un  nouvel  anesthesique  local,  la  stovaine," 
Bull,  de  Lyon  med..  May  15,  1904. 

Polini,  Gr. :  "La  stovaina  in  chirurgia,"  Gazz.  internaz.  di  medic, 
Naples,  Oct.,  1905. 

Poth,  H. :  "Ueber  Stovaine  als  lokales  Anaesthetikum  in  der  kleinen 
Chirurgie,"  Med.  Klinik,  1905,  No.  15. 

Pouchet:  "fitude  pharmacodynamique  de  la  stovaine,"  Acad,  de 
Med.,  Paris,  July  12,  1904;  Eevue  de  Therap.,  1904,  543. 

Pouliquen :     "La  rachistovainisation,"  These  de  Paris,  1905. 

Preindlsberger :    Allg.  med.  Zentral-Ztg.,  1905,  No.  42,  808. 

Preliminary  Report  of  the  Anesthesia  Commission  of  the  American 
Medical  Association.  Transactions  of  the  Section  on  Surgery  and  Anat- 
omy of  the  American  Medical  Association,  1908,  426-427,  A.  M.  A. 
Press. 

Pringle :  "Notes  of  an  Experience  of  Stovaine  as  a  Spinal  Analgesic 
in  100  Cases,"  Brit.  Med.  J.,  1907,  No.  2427, 12. 

Pussep :    Arch.  f.  Psych.,  1911,  No.  48,  2. 

Eabourdin,  A. :  "Topographic  des  alterations  sensitives  dans  rachi- 
stovainisation,"  These  de  Paris,  1906. 

Eahn,  A. :  "Die  Ersatzmittel  des  Kokains,"  Pharm.  Cent.,  Sept.  28, 
1905;  "Ueber  Stovaine  in  der  Lumbal-Ansesthesie,"  Deut.  Aerzte-Ztg., 
Apr.  15,  1906. 

Eavant:  "Anesthesie  chirurgicale  limitee  a  la  region  genito-pe- 
rineoanale  par  I'injection  intra-rachidienne  de  solution  concentree,"  Soc. 
de  Biol.,  seance  du  22  juin,  1907. 

Eeclus,  P.:  "L'Analgesie  locale  par  la  Stovaine,"  Academic  de  Mede- 
cine,  Paris,  July  5,  1904;  Revue  de  Therap.,  1904,  595.  "La  Stovaine," 
Presse  med.,  Jan.  3,  1906. 

Eoith:    Munch,  med.  Woch.,  1907,  No.  19. 

Eoyet :  "Behandlung  der  Ozsena  mit  Stovaine,"  Wiener  hlin.  therap. 
Woch.,  1906,  No.  10. 

Euschhaupt:  "Lumbalanasthesie  mit  Stovaine,"  Med.-  Gesell.  in 
Giessen,  Feb.  20,  1906. 

Euthon :  "Sur  un  nouvel  anesthesique :  la  stovaine,"  These  de  Paris, 
1904. 

Sandberg,  J. :    "Spinalanalgesie,"  Med.  Rev.,  Dec,  1905. 

Saratucci:     II  Policlinico,  1907,  No.  9. 

Sauvez,  E. :  "Un  nouvel  anesthesique  local :  la  stovaine,"  Soc. 
d'Odontologie,  Apr.  9,  1904;  Rev.  internat.  Med.  et  Chir.,  1904,  191. 
"L' Anesthesie  locale  pour  I'extraction  des  dents,"  Archiv.  de  Therap., 
Aug.  1,  1905.  "Quelle  est  la  meilleure  methode  d'anesthesie  locale  pour 
I'extraction  des  dents  ?"  La  clinique,  Aug.  3, 1906,  505. 


828  ANESTHESIA 

Schiff:  "Ueber  Stovaine  als  lokales  Ansesthetikum/'  Deut.  med. 
Woch.,  Aug.  31,  1905. 

Schwarz :    Zentr.  f.  Cliir.,  1907,  No.  13. 

Scrini :  "Precis  de  therapeutique  oculaire,"  Paris :  G.  Steinheil,  edit. 
1904.  "La  stovaine,"  Arcli.  d'OphlJialmol.,  June  15,  1905.  "Sur  la  sto- 
vaine," Paris,  Soc.  de  Therap.,  Oct.  10,  1906. 

Silbermark,  M. :  "Ueber  Spinalanalgesie,"  Wiener  Tclin.  Woch.,  Nov., 
1904,-  No.  46. 

Sinclair,  A. :  "Gangrene  of  the  Skin  Following  the  Use  of  Stovaine, 
a  New  Local  Anesthetic,"  Cutan.  Dis.  inch  Syph.,  1904:,  13,  307,  310; 
Tlierap.  Monats.,  1905,  No.  11,  595.  .'  ■• 

Sluss,  J.  W. :    "Spinal  Analgesia,"  Indiana  Med.  J.,  June  12,  1906. 

Sonnenburg:  "Eiickenmarksanasthesie  naittels  Stovaine,"  Deut. 
med.  Woch.,  1905,  No.  9.  j;  ' 

Spiller  and  Leopold:    Deut.  med.  Woch.,  1910,  1292. 

Stephenson:  "Stovaine:  a  New  Local  Anesthetic,"  Ophtlialmoscope, 
Nov.,  1904;  Bev.  de  Therap.,  1905,  128. 

Tilmann,  0. :  "Lumbalanasthesie  mit  Stovaine,"  Berl.  Tclin.  WocTi., 
Aug.  21,  1905.  v. ' 

Tomai,  G. :  "L'anestesia  stovainica,"  Giorn.  internaz.  d.  sc.  mediche, 
Feb.  28,  1906. 

Trautenroth:     Deut.  med.  Woclt.,  1906,  No.  7. 

Tuflier,  Th. :  "Die  Riickenniarksanasthesie  mit  Stovaine,"  Klin, 
tlierap.  Woch.,  1905,  378. 

Varvaro,  E. :  //  PolicUno,  1906,  Nos.  6,  7,  8. 

Wainwright,  J.  M. :  "On  the  Yalue  of  Spinal  Analgesia  in  Shock,"' 
Pe/m.  ilieii.  J.,  Nov.,  1905. 

Wendel:  "Die  modernen  Bestrebungen  zur  Verminderung  der 
Narkowengefahr,"  Munch,  med.  Wocli.,  1906,  1601. 

Wilms:  "Heilung  hysterischer  Kontrakturen  durch  Lumballah- 
mung,"  Deut.  med.  Woch.,  June  14,  1906. 

Wolff,  L. :  "Ein  neues  cocainfreies  Injections-Anasthetikum,";  AZ/^. 
mediz.  Central. -Ztg.,  1906,  No.  13.  ,  }• 

Woskresenski,  A.  W. :  "Ueber  lokale  Stovaine  Anasthesie,"  Fxiftschr. 
der  Med.,  1905,  506. 

Zahradnicky:  "The  Eesults  of  Spinal  Anesthesia,  Especially  in 
Laparotomy,"  Archiv  f.  hlin.  Ohir.,  98,  No.  2;  Extract  in  Therap.  Oaz., 
Sept.  15,  1909. 

Zernik  (F)  :    "Stovaine,"  Apoth.-Ztg.,  1905,  No.  19. 

Zwintz  (J.)  :  "Ueber  Stovaine,  ein  pharmako-dynamische  Studie," 
Wien.  med.  Presse,  Feb.  4,  1906,  No.  5. 

Stovain  Billon. — Contains,  in  1  c.  c,  0.00013  gm,  epirenin  borate, 
0.04  gm.  stovain,  and  0.0011  gm.   sodium  chlorid. 

Stovain  with  Strychnin. — On  the  use  of  stovain  with  strychnin  for 


A   LIST    OF   ANESTHETICS  829 

spinal  anesthesia,  see  Z.  fur  Cliir.,  107,  1-3 ;  Therap.  Gaz.,  June  15, 
1911. 

Strophanthin. — Strophanthin  (strophanthinuni,  strophanti n)  is,  ac- 
cording to  the  United  States  Pharmacopoeia,  a  glucosid,  or  mixture  of 
glucosids,  obtained  from  strophanthus ;  it  was  made  official  in  the 
eighth  revision  of  the  Pliarmacopceia.  It  is  officially  described  as  a 
white  or  faintly  yellowish  crystalline  powder,  containing  varying 
amounts  of  water  of  crystallization,  which  it  does  not  lose  entirely  with- 
out decomposition.  Its  taste  is  intensely  bitter,  and  it  is  permanent  in 
the  air.  It  is  very  soluble  in  water  and  in  dilute  alcohol,  but  is  less 
soluble  in  absolute  alcohol,  and  is  nearly  insoluble  in  ether,  chloroform, 
and  benzene.  It  commences  to  fuse  at  -\-  170°  C,  and  is  not  completely 
melted  until  the  temperature  of  -|-  190°  C.  is  reached.  Its  solutions  are 
dextrogyrate,  and  are  neutral  to  litmus.  Fraser  {Am.  J.  Pliarm.,  1889, 
532)  found  that  strophanthin  was  difficult  to  separate,  but  obtained  it 
pure  by  a  process  depending  upon  the  formation  of  a  tannate  and  sub- 
sequent decomposition  by  lead  oxid.  It  yielded,  upon  analysis,  results 
corresponding  to  the  formula  CooHg^Oio-  Thoms  (Ber.,  1898,  534)  pre- 
pared pure  strophanthin.  Arnaud  gave  its  formula  as  Q^-J1^^0-^^o,  and  his 
results  were  confirmed  by  Kohn  and  Kulisch;  Feist  reported  C^oHgeOg. 
Thoms  found  that  the  strophanthins  as  obtained  from  different  species 
differed  somewhat  in  composition;  he  proposes  designating  them  as  fol- 
lows: k-stropliarithin  when  obtained  from  S.  komhe;  g -strophanthin 
when  prepared  from  S.  gratus;  e-strophanthin  when  from  S.  emini;  and 
h-strophanthin  when  from  ^S*.  hispidus. 

On  the  properties  of  strophanthin,  see  Hardy  and  Gallois :  J. 
Pharm.  Chim.  (3),  25,  176,  and  Fraser:  Pharm.  J.,  July  23,  1886.  On 
the  physiological  action  of  strophanthus  preparations,  see  Steinach: 
Wiener  klin.  Woch.,  1888.  The  local  anesthetic  action  of  strophanthin 
and  Ouabain  (q.  v.)  has  been  discussed  by  Panas:  Bull,  de  I'Acad.  de 
Med.  de  Paris,  1890,  No.  7. 

Sturmann's  Solution. — A  local  anesthetic  containing :  Cocain  hydro- 
chlorid,  1.0;  tincture  iodin  (decolorized),  phenol,  aa.,  0.3;  glycerin, 
10.0;  water  to  100.0;  and  2  drops  of  a  1 :  1,000  suprarenin  hydrochlorid 
solution  are  added  per  c.  c. 

Subcain. — A  solution  containing  1  per  cent  cocain,  0.0065  suprare- 
nin borate,  0.1  per  cent  salicylic  acid,  0.8  per  cent  sodium  chlorid,  and 
eucalj'ptol. 

Subcutin  (Subcutol;  Ancesthesinum  solubile;  paraphenol  sulphonate 
of-  ansesthesin;  paraphenol  sulphonic  acid  of  para-amidobenzoic  acid 
ethyl  ester). — A  local  anesthetic  used  like  anoisthesin. 


„  ,        .         /  /NH2.S03H.C6H40H\ 

Subcutm.— I  CeHZ  1 

V         ^COOCjHs  / 


is  a  fine,  white,  needle-shaped 


830  ANESTHESIA 

crystalline  powder,  melting  at  +  195.6°  C,  and  soluble  in  cold 
water,  1:100,  and  in  warm  water  (body  temperature),  2.5:100.  On 
contact  with  the  tongue,  it  produces  a  sensation  of  numbness.  It  is 
stable  in  solution  and  on  boiling — an  advantage  over  cocain,  which  does 
not  keep  so  well.  On  the  chemistry  of  subcutin,  see  Eitsert :  Pharm.-Ztg., 
5Jf:,  797.  The  fact  that  Ancestliesin  {q.  v.)  is  almost  insoluble  in  water 
and  that  it  therefore  is  not  well  adapted  for  the  preparation  of  media 
suitable  for  injection  led  Eitsert  to  study  a  whole  group  of  anesthesin 
compounds  with  a  view  of  determining  whether  any  of  them  was  endowed 
with  greater  solubility,  and  yet  mild  in  its  action  and  free  from  irritat- 
ing properties.  He  ascertained  that  the  phenol  sulphonate,  or  subcutin, 
answered  these  requirements. 

It  has  been  shown  that  subcutin  exerts  an  inhibitory  action  on  the 
propagation  of  the  pathogenic  micro-organisms  of  typhoid  and  cholera. 
It  is  said  to  be  free  from  all  untoward  by-effects;  and  it  has  been  demon- 
strated experimentally  that  doses  such  as  are  not  required  in  major 
operations  are  always  well  tolerated.  It  may  be  said,  therefore,  that 
subcutin  is  nontoxic  for  all  practical  purposes,  especially  since  experi- 
ments on  animals  demonstrated  that  1.6  gra.  per  kg.  of  body  weight  might 
be  administered  without  danger.  See  Ancesthesin.  On  subcutin,  see  es- 
pecially Becker:  Miinch.  med.  Woch.,  1903,  50,  No.  20,  857.  "Sub- 
cutin-mundwasser"  is  a  2  per  cent  subcutin  solution. 

Sulzberger's  Local  Angesthetic. — Nathan  Sulzberger,  in  U.  S.  Patent 
949,134,  February  15,  1910,  announces  a  local  anesthetic,  consisting  of  a 
10  per  cent  solution  of  cocain  in  phenyl  acetate  with  a  very  small  per- 
centage of  adrenalin.  Ethyl  acetate  and  phenyl  stearate  are  also  claimed 
as  solvents  of  menthol  or  cocain. 

Summopon. — This  preparation  contains  the  alkaloids  of  opium 
(Chem.-Zentr.,  1912,  1,1672).     8ee  Pantopon. 

Suppositoires  Adreno-styptiques. — Each  contains  0.00035  gm.  adre- 
nalin and  0.2  gm.  ansesthesin-stovain.  These  are  used  in  the  treatment 
of  hemorrhoids. 

Suprarenal-tonogen. — A  water  solution  of  0.1  per  cent  suprarenal 
extract,  0.5  per  cent  chloretone,  and  0.7  per  cent  sodium  chlorid. 

Suprarenin. — o-Dioxyphenylethanolmethylamin 

[  (OH)  2CeH3.CH0H.CH2.NHCH3] 
is  a  grayish  white  powder  which  has  a  melting  point  of  -\-  210-212°  C. 
It  is  a  hemostatic  and  astringent,  and  is  used  in  combination  with  vari- 
ous local,  anesthetics,  as,  for  example.  Novocain  (q.  v.).  Synthetic  su- 
prarenin has  the  same  uses;  suprarenin  borate  and  hydrochlorid  are 
also  used  in  combination  with  cocain  and  other  local  anesthetics. 

Suprarenin-cocain  Tablets. — See  Braun's  Suprarenin-tabletten. 

Terpentinchlorhydrate. — See  Terpin  Hydrochlorid. 

Terpentinkampfer. — See  Terpin  Hydrochlorid. 


A   LIST    OF    ANESTHETICS  831 

Terpin  Hydrochlorid  (Terpiiichlorliydrate). — CjoITio-HCl  is  a  cam- 
phoraceous  mass,  melting  at  -\-  ]25°  C;  it  is  said  to  bo  used  as  a  local 
anesthetic  in  combination  with  phenol. 

Tetrachlorethane  (Sym.). — Symmetrical  tetrachlorethane  (acetylene 
tetrachlorid ;  "westron'"),  C2H2CI4,  is  slightly  anesthetic  (Clement  and 
Reviere:  "Caoutchouc  ct  Gutta-percha,"  7,  4021)  ;  but  under  the  con- 
ditions of  its  use  as  an  extraction  material  and  solvent  in  factories,  its 
narcotic  effects,  as  well  as  those  of  trichlorethylen,  which  is  less  active 
physiologically,  are  said  to  be  less  than  those  of  some  of  the  other  solv- 
ents (see,  on  this  point,  Chem.-Ztg.,  32,  529). 

Tetrahydronaphthalene. — According  to  Brissemoret  (Compt.  rend. 
Soc.  hiol.,  69,  497),  this  compound  has  a  narcotizing  power  on  such 
warm-blooded  animals  as  the  rabbit. 

Tetramethyldiaminodimethylethylcarbinol  Cinnamate  Hydrochlorid. 
— This  is  an  alypin,  in  which  cinnamic  acid  takes  the  place  of  benzoic 
acid;  it  is  said  to  produce  an  anesthetic  effect  lasting  twice  as  long  as 
that  effected  by  the  same  quantity  of  cocain  (Farbenfabriken  vorni. 
Friedr.  Bayer  &  Co.,  German  Patent  173,631). 

Thibault's  Local  Anaesthetic. — In  1907  Thibault  suggested  the  em- 
ployment of  quinin  and  urea  hydrochlorid  as  a  local  anesthetic  in  opera- 
tions usually  performed  with  cocain. 

See  Quinin  and  Urea  Ilydroclilorid. 

Thymocain. — This  local  anesthetic,  said  to  be  without  toxic  action 
when  used  subcutaneously,  contains  about  1  per  cent  cocain  hydrochlorid 
and  1  per  cent  sodium  chlorid  in  water  solution,  also  very  small  amounts 
of  alcohol,  thymol,  and  a  suprarenal  gland  preparation. 

Thymoform. — This  preparation,  intended  for  use  in  the  treatment  of 
teeth,  contains  thymol,  alum,  formaldehyd,  and  creosote. 

Tonocainum  Suprarenale  Richter. — A  sterilized  tonogen-eucain  solu- 
tion. 

Tonogen  Suprarenale  Richter.' — A  solution  (1:1,000)  of  extract  of 
suprarenal  gland  with  an  addition  of  0.5  per  cent  of  chloretone  and  0.7 
per  cent  sodium  chlorid. 

Townley's  Anodyne  Mixture. — James  Townley  ("Parturition  AYith- 
out  Pain  or  Loss  of  Consciousness,"  London,  1863)  recommended  the 
employment  of  an  anodyne  mixture  composed  of  "alcohol,  two  ounces; 
one  drachm  of  aromatic  tincture;  with  sufficient  chloroform  added  short 
of  the  production  of  a  turbid  state  of  the  fluid.'^  The  formula  of  the 
aromatic  tincture  was  as  follows:  "One  drachm  of  nutmegs;  two 
drachms  of  cloves;  pterocarp  chips,  a  drachm  and  a  half;  water,  four 
ounces;  alcohol,  five  ounces."  This  mixture  was  successfully  used  by 
Townley  in  obstetrical  practice  for  the  purpose  of  blunting  the  sensibil- 
ity to  pain  without  the  abolition  of  consciousness. 

Trichlorethane. — a-trichlorethane     (monbchlorethylene   chlorid). 


832  ANESTHESIA 

CH0CI.CHCI2,  is  a  colorless  liquid,  boiling  at  -|-  37°  C.  The  readiness 
with  which  it  is  formed  by  the  action  of  potassium  hydroxid  upon  tri- 
chlorethane  suggested  the  hypothesis  that  the  anesthetic  effects  of  this 
last  are  really  attributable  to  the  liberation  of  dichlorethylene  in  the 
blood.  This  view  was  advanced  by  Tauber,  of  Jena,  who  experimented 
with  the  isomeric  trichlorethanes  for  the  purpose  of  determining  their 
anesthetic  value.  His  observations  were  made  upon  frogs,  pigeons, 
guinea-pigs,  rabbits,  and  dogs;  a  few  drops  were  sufficient  to  produce 
complete  anesthesia  in  the  smaller  animals.  '   ■■ 

Methylchloroform  (mono-chlorethylidene  chlorid),  CH3.CCI3. — This 
was  also  studied  by  Tauber.  Administered  in  the  form  of  vapor  to 
frogs  and  rabbits  it  produced  a  satisfactory  anesthesia,  without  any 
marked  effect  upon  respiration  or  circulation.  Upon  himself  Tauber 
experimented  by  inhaling  the  vapor  of  about  20  gm.  under  the  super- 
vision of  von  Langenbeck.  There  was  no  stage  of  excitement  preceding 
anesthesia;  respiration  remained  undisturbed;  the  pulse  did  not  exceed 
eighty-four  beats  per  minute;  it  was  regular,  and  exhibited  no  evi- 
dence of  diminishing  blood  pressure.  Complete  anesthesia  was  reached 
in  five  and  a  half  minutes,  and  it  continued  for  10  miputes  longer. 
Vomiting  occurred  soon  after  the  recovery  of  consciousness,  breakfast 
having  been  eaten  about  two  hours  before  the  experiment.  A  feeling  of 
general  discomfort  persisted  for  about  an  hour,  after  which  it  disap- 
peared, leaving  no  unpleasant  effects  behind.  See  Brit.  Med.  J.,  Nov. 
13,  1880. 

Trichlorethylene  Dichlorid. — See  /Ether  arkestheticus  aranii. 

Trichlorurum  Formili, — See  Chloroform. 

Trimethylbenzoxypiperidinum  hydrochloricum. — See  Eucain-B. 

Trimethylethylene. — Prepared,  according  to  von  Mering  (Eng.  Pat. 
11,844,  1891),  from  tertiary  amyl.  alcohol  by  action  of :  water-abstract- 
ing agents;  claimed  by  him  to  be  superior  to  "amylene"  from  fusel  oil. 
See  Pental.  ■  ' ,        '    .:      ■ 

Tropacocain  or  Tropacocain  Hydrochlorid  ( Tropacocaihse  Hydro- 
chloridum) . — Benzoylpseudotropein  hydrochlorid,  tropein,  tropacocain 
hydrochlorid  [C8Hi,N0(C,H50)HCl  =  Ci,Hi„N0'2.HCl]  is  the  hydro- 
chlorid of  synthetic  tropacocain.  It  was  found'  in  1891  by  Giesel 
(Pharm.-Ztg.,  1891,  419)  in  the  leaves  of  the  Japanese  coca  plant,  and 
subsequently  it  was  examined  by  Liebermann  very  accurately  (Ber., 
1891,  2336;  1892,  927).  Liebermann  also  succeeded  in  reproducing  it 
by  synthesis  from  its  components,  and  in  this  manner  he  obtained  a 
purer  and  more  active  preparation  than  the  natural  vegetable  base. 
Willstatter  (Ber.,  29,  393,  936,  1575,  2216)  indicated  a  method  by 
which  benzoylpseudotropeine  might  be  obtained  from  tropin,  and  this 
method  was  patented  and  a  cheaper  preparation  was  obtained. 

Pseudotropin-Liebermann. — Pselidotropin-Liebermann     is     obtained 


A   LIST    OF    ANESTHETICS  833 

from  tropinon  or  from  tropin  by  electrolytic  reduction,  and  from 
this  the  benzoyl  derivative  is  obtained,  and  this  is  converted  into  tlie 
hydrochlorid.  It  forms  colorless,  needle-shaped  crystals,  melting  at 
-f  271°  C.  (519.8°  F.).  It  is  readily  soluble  in  water,  and  its  solution 
keeps  well  for  several  months.  Heated  in  the  presence  of  hydrochloric 
acid,  it  is  split  up  into  benzoic  acid  and  tropin.  Its  incompatibilities  are 
the  same  as  those  of  the  alkaloids  in  general. 

Benzoylpseudotropein. — Benzoylpseudotropein  was  tested  physiologi- 
cally by  Chadbourne  (Brit.  Med.  J.,  1892,  402)  soon  after  its  discovery, 
and  it  was  he  who  recommended  it  under  the  name  of  tropacocain  as  a 
local  anesthetic  and  cocain  substitute.  He  found  it  to  be  less  than  half  as 
poisonous  as  cocain,  and  he  regarded  it  in  particular  as  a  much  milder 
poison  in  its  action  upon  muscles  and  motor  centers.  Its  solutions  may 
be  boiled  indefinitely  for  purposes  of  sterilization. 

Tropacocain  Hydrochlorid. — Tropacocain  hydrochlorid  is  now  em- 
ployed as  a  local  anesthetic  instead  of  cocain  hydrochlorid;  the  solution 
is  said  to  be  more  stable,  easily  sterilizable,  and  to  have  a  less  depressing 
action  on  the  heart.  It  is  used  in  ophthalmology,  dentistry,  general  sur- 
gery by  the  Schleieh  infiltration  method,  in  regional  anesthesia  accord- 
ing to  Oberst,  and  in  lumbar  anesthesia  in  accordance  with  Bier's 
method. 

Dosage. — It  is  applied  in  3  to  10  per  cent  water  solutions  containing 
0.6  per  cent  sodium  chlorid. 

On  Tropacocain  Hydrochlorid,  see  the  following  contributions: 

Chadbourne:  Therap.  Monalsh.,  1892,  471;  Brit.  Med.  J.,  1892, 
Ko.  2. 

Schweigger  and  Silex :    Therap.  Monatsli.,  1892,  473. 

Pinet  and  Viau-.  Comm.  faites  a  la  Soc.  d'Ontolog.  de  Paris.,  Dec. 
6,  1892;  Jan.  10,  1893. 

Hagenschmidt :    Sem.  mid.,  1893,  No.  6. 

Ferdinands :    Brit.  Med.  J.,  1893,  1318. 

Groenouw:     Deut.  med.  Woch.,  1893,  No.  26,  331. 

Bockenham:     Sem  mid.,  1893,  536;  Brit.  Med.  J.,  Nov.  18,  1893. 

Veasey:    N.  Y.  Med.  J.,  Nov.  25,  1893. 

Seifert:     Internat.  hlin.  Rundschau,  1893,  No.  8. 

In  1893  a  3  per  cent  solution  was  generally  used  to  produce  local 
anesthesia,  and  it  was  observed  that  stronger  solutions,  such  as  a  5  per 
cent  one,  under  certain  circumstances,  caused  undesirable  results. 

Vamossy:     Therap.  Woch.,  1896,  No.  9. 

Hattyasy:     Oest.-ungar.  Vierteljalirs.  f.  Zahnhlhde,  1896,  161. 

Eogman:     Cli^i.  ophthal.,  1897,  Nos.  17  and  19. 

Blaskovics :    Pest.  med.  chir.  presse,  1896,  No.  50. 

Dillenz:    Dissertation,  Ziirich,  1897. 

Custer:    Miinch.  med.  Woch.,  1898,  No.  32. 


834  ANESTHESIA 

Braun:  Central}),  f.  Chir.,  1897,  'No.  17;  Yolkmann's :"  Sammlung 
Jclin.  Vortrilge,  1898,  No.  228. 

Hilbert:    Ophthalmiat.  Klinik,  1899,  No.  11. 

Schmitt :    Bev.  med.  de  VEst,  1898,  No.  20. 

Brieglieb:   Z.  f.  praktische  Aerzte,  1899,  No.  6. 

Dorn:  ^  Odontol.  Blatter,  1899. 

Seifert:    Inter.  Jclin.  Rundschau,  1899,  No.  8. 

Lang:    Gyogydszat,  Dec.  10,  1899. 

Albrecht :   Odontol.  Blatter,  Apr.,  1899. 

Blocli:    Centralh.  f.  d.  gesammte  Therap.,  1900,  No.  1. 

Bauer:    Oest.-Ungar.  Vierteljahrs.  f.  Zalinlieilh.,  Apr.,  1900. 

Zander :    Deut.  zahndrztl.  Woch.,  1900,  No.  128. 

Vennerholm:    Z.  f.  Tliiermedizin,  1900,  164. 

Schwarz:    Centralh.  f.  Chir.,  1901,  No.  9,  248. 

Meyer:    Med.  Netus,  Apr.  13,  1901. 

Neugebauer :    Wien.  Jclin.  Woch.,  1901,  Nos.  50  and  52. 

The  last  three  authors  advocated  the  preparation  for  medullary  anes- 
thesia by  Bier's  method. 

Kopfstein:    Wien.  Jclin.  BundscJiau,  1901,  No.  49, 

Saum:    Deut.  zalmdrztl.  Woch.,  1901,  156. 

Eeissenbach:    Deut.  zaJmdrztl.  Ztg.,  1901,  No.  5. 

Bloch :     Wien.  zalmdrztl.  Woch.,  1901,  Nos.  2  and  3. 

Deak:   Magyar  Fogaszati  Szemle,  1901,  No.  2. 

The  last  four  authors  imanimously  praised  the  prompt  anesthetic 
properties  of  the  preparation  in  extractions  of  teeth. 

Annin:    Wratsch,  1901,  No.  11,  346. 

Annin  used  the  preparation  successfully  in  ophthalmic  surgery, 

Schwarz:   Milnch.  med.  Woch.,  1902,  No.  4. 

This  author  reported  on  over  100  cases  of  medullary  analgesia  by 
Tropacocain. 

Illing:    J.  Am.  Med.  Assn.,  1901,  No.  12. 

Neugebauer:    Miinch.  med.  Woch.,  1902,  No.  44,  1862. 

Kozlowsky :   Przeglad  lekarsJci,  1902,  No.  4. 

Kamann :   Miinch.  med.  WocJi.,  May  20,  1902. 

Schleich:    Deut.  Klinik,  1902,  22. 

Mobilio:    Arcliivio  d'oftalmologia,  Sept.  and  Oct.,  1902. 

Fuchs-Golding :   Zalmdrztl.  Rundschau,  1902,  No.  499. 

Vogt:    Oest.-Ungar.  Vierteljahrs.  f.  Zahnheil.,  1902,  No.  1. 

Loves:   Die  Zahnkunst,  1902,  No.  26. 

The  last  three  authors  used  the  preparation  with  advantage  in  den- 
tistry, for  the  production  of  local  anesthesia  during  extractions. 

Preindlsberger :    Wiener  med.  Woch.,  1903,  No.  34. 

This  author  confirmed  the  observations  recorded  by  Neugebauer  and 


A   LIST    OF    ANESTHETICS  835 

others  on  the  application  of  the  preparation  in  the  method  of  anesthesia 
of  the  spine. 

Bloch:    Beut.  med.  Wocli.,  1903,  No.  24;  Ver.  Beil,  188. 

Triesch:  Bericht  iiber  die  31.  Hauptversammlung  hessicher  Zahn- 
drzte,  1902;  Odontol  Blatter,  1,  Nos.  15-17. 

Triesch  used  5  per  cent  injections  of  tropacocain  in  dentistry,  heing 
thus  able  to  induce  a  satisfactory  anesthesia.  He  found  that  although 
the  action  of  tropacocain  was  less  prompt  than  that  of  cocain,  it  had 
the  advantage  over  the  latter  in  being  less  poisonous  and  dangerous. 

Eydygier:    Przeglad  leTcarshi,  1904,  No.  7. 

This  author  reported  on  the  success  which  attended  the  application 
of  tropacocain  as  an  anesthetic  for  the  spinal  cord  by  Kozlowski's  method 
in  49  cases  treated  at  the  Lemberg  Hospital. 

Stolz:   Archiv  f.  Gyndkol.,  73,  No.  3. 

Stolz  summarized  the  results  of  his  large  experience  in  connection 
with  the  anesthesia  of  the  spinal  cord  as  applied  to  gynecology  and 
obstetrics. 

Bellandi :  "L'Analgesie  chirurgicale  par  voie  rachidienne  au  moyen 
de  la  tropacocaine,"  Alexandrie,  1903. 

Levy:    Deut.  zdhndrztliche  Woch.,  1904,  No.  18. 

Matthes:    Ihid.,  1904,  No.  11. 

Preindlsberger :  Yersammlung  deut.  Natur for  seller  und  Aerzte  in 
Meran,  1905;  Allg.  med.  Zentral-Ztg.,  1905,  No.  42,  808;  and  Wiener 
klin.  Woch.,  1905,  No.  26. 

Trautenroth:   Deut.  med.  Woch.,  1906,  253. 

The  last  two  authors  described  tropacocain  as  preferable  to  stovain 
in  connection  with  the  anesthesia  of  the  spine. 

Franceschi:  Allg.  med.  Zentral-Ztg.,  1905,  No.  42,  809,  and  No. 
43,  827.  Klin.-therap.  Woch.,  1906,  No.  41;  Mwich.  med.  Woch.,  1906, 
1933. 

Koder:    Wiener  med.  Woch.,  1905,  No.  37,  1781. 

Colombani :    Wiener  hlin.  Woch.,  1905,  No.  21,  538. 

Foster:   Beitr.  zur  Tclin.  Chir.,  1905,  ^6,  No.  1. 

Zahradnicky:    Wiener  med.  Ztg.,  1905,  No.  5,  55. 

Karas:    Wiener  med.  Woch.,  1905,  Nos.  20  and  21. 

Yolker:  Monats.  f.  Gehurtshilfe  und  GyndTcol.,  1905,  No.  4;  Miinch. 
med.  Woch.,  1905,  No.  33,  1612. 

Eibolla:   Stomatologia,  1905,  No.  3. 

Eibolla  secured  excellent  results  by  the  use  of  tropacocain  as  a  local 
anesthetic  in  dental  operations. 

Becher:   Dissertation,  Giessen,  1905. 

Becher  demonstrated  the  remarkable  efficacy  of  tropacocain  in  medul- 
lary application  to  animals. 


836  ANESTHESIA 

Slajmer:    Wiener  med.  Presse,  1906,  Nos.  22  and  23. 

This  author  was  of  the  opinion  that  even  anesthesia  by  inhalation 
could  not  compete  with  tropacocain  anesthesia.  His  operations  included 
1,200  cases. 

Schwarz:  Wiener  Min.  Wocli.,  1906,  No.  30;  Presse  med.,  1906, 
No.  64. 

Arit:   MilncJi.  med.  Woch.,  1906,  No.  34. 

Baisch :  Deut.  med.  Woch.,  1906,  No.  38. 

Baisch  combined  tropacocain  anesthesia  with  scopolamin-morphin 
hypnosis  for  gynecological  operations,  and  the  method  was  found  to 
present  various  advantages. 

Miiller :   Monats.  f.  Gehurtsliilfe  und  Gyndh.,  1905,  No.  2. 

Donitz:    MiLnch.  med.  Wocli.,  1906,  No.  28. 

Kocher:    Wiener  med.  Presse,  1906,  1039. 

Kiimmell:   Med.  KliniJc,  1906,  No.  43,  1120. 

According  to  Kiimmell,  tropacocain  proved,  in  the  Eppendorf  Gen- 
eral Hospital  of  Hamburg,  to  be  the  best  and  the  least  poisonous,  easy  to 
sterilize,  and  a  constant  anesthetic. 

Bier  (ibid.)  expressed  the  opinion  that  the  dangers  of  spinal  anal- 
gesia were  due  to  the  selection  of  unsuitable  drugs.  In  1906,  he  an- 
nounced that  he  considered  that  tropacocain  was  the  most  suitable  prepa- 
ration. 

Ach:   MUnch.  med.  Woch.,  1907,  No.  33,  624. 

Ach  described  the  results  of  lumbar  anesthesia  in  400  cases.  He 
concluded  that,  of  the  drugs  recommended  for  lumbar  puncture,  the 
least  harmful,  namely,  tropacocain,  should  be  selected. 

Thorbecke:    Med.  Klinih,  1907,  No.  14,  386. 

Gallatia:    Gynakol.  Rundschau,  1907,  No.  11. 

Bosse:    Deut.  med.  Woch.,  1907,  No.  5. 

Goldschwend:    Wiener  Min.  Woch.,  1907,  No.  37,  1098. 

This  author  had  very  satisfactory  results  with  tropacocain,  even  in 
the  most  serious  laparotomies. 

Masotti  and  Angeletti:  Revista  Veneta  di  scienze  mediche,  Jl{.7,  Nos. 
8  and  9;  Deut.  Med.  Ztg.,  1908,  No.  14,  149. 

Eemenar:    Wiener  Min.  Woch.,  1907,  No.  45,  1397. 

Gilmer:    Miinch.  med.  Woch.,  1907,  No.  38,  1904. 

Baum:   Ibid.,  1905. 

Seitz:   Ibid.,  1905. 

Preindlsberger :    Wiener  Tclin.  Rundschau,  1907,  No.  46. 

Valenta :    Gynakol.  Rundschau,  1908,  No.  1. 

The  eight  authors  last  mentioned  gave  favorable  accounts  of  tropa- 
cocain and  its  lumbar  use. 

Bloch:    Heilhunde,  1906,  No.  2. 

Bloch  reported  on  the  employment  of  tropacocain  in  general  medi- 


A   LIST    OF    ANESTHETICS  837 

cal  practice.  He  found  it  to  be  a  never-failing  remedy  in  ophthalmic 
and  dental  practice. 

Erhardt:  Woch.  f.  Tierheilk.,  1908,  Nos.  27  and  28;  Miinch.  med. 
Woch.,  1908,  Nos.  19  and  26. 

Erhardt  found  that  the  addition  of  3  per  cent  gum  acacia  to  a  1  per 
cent  solution  of  tropacocain  diminished  the  toxicity  of  the  anesthetic 
in  lumbar  anesthesia.     See  Erhardt' s  Solutions. 

Donitz:   Miinch.  med.  Woch.,  1908,  No.  32. 

Strauss:   Med.  Klinil,  1908,  No.  6. 

Masotti  and  Angeletti:  Revista  Veneta  di  scienze  mediche,  1908, 
No.  6. 

Saggini:    Giornale  di  medicina  militare,  Apr.,  1908. 

Hartleib :   Miinch.  med.  Woch.,  1908,  No.  5. 

Valenta:    Gynakol.  Rundschau,  1908,  No.  1. 

Eemenar:    Wiener  Min.  Woch.,  1908,  No.  45. 

Tomaschewski :   Deut.  med.  Woch.,  1908,  No.  51. 

Klein :   Miinch.  med.  Woch.,  1908,  No.  47. 

The  last  eight  contributions  relate  to  the  use  of  tropacocain  in  spinal 
anesthesia. 

Colombani :    Wiener  Jclin.  Woch.,  1909,  No.  39,  1336. 

Colombani  gave  a  detailed  report  of  1,100  cases  of  spinal  anesthesia, 
showing  that  tropacocain  afforded  excellent  results. 

Slajmer:   Med.  Blatter,  1909,  No.  47. 

Eieck:   Zentralh.  f.  Gynakol,  1909,  No.  41,  1429. 

Klose  and  Vogt:  Mitteil.  aus  den  Grenzgehieten  der  Med.  und  Chir., 
19,  No.  5;  Zentralh.  f.  innere  Med.,  1909,  965. 

The  last  paper  was  the  result  of  an  experimental  investigation  on 
spinal  anesthesia. 

Heinz:    Wiener  med.  Woch.,  1910,  No.  37. 

Slajmer:   Beitr.  zur  Jclin.  Chir.,  1910,  67. 

Arlt:   Miinch.  med.  Woch.,  1910,  No.  28. 

Morrison:   Lancet,  Sept.  10,  1910. 

The  last  four  papers  relate  to  lumbar  anesthesia  induced  with  tropa- 
cocain. 

Budde :    Deut.  militdrdrztl.  Z.,  1911,  No.  4,  168. 

Gros:    RiedeVs  Mentor,  1911,  44. 

Tropein  or  Tropeine. — See  Tropacocain. 

Turpentine. — Turpentine  oil  was  proposed  as  an  anesthetic  by  Nun- 
neley  in  1849.  It  has  been  used  in  emergencies  with  success;  it  has  also 
been  added  to  chloroform  to  prevent  collapse.  Eichardson  {Sci.  Am. 
Suppl.,  No.  516,  8240)  found  that  the  vapor  of  turpentine  was  irritating 
at  first  and  difficult  to  breathe,  but  that  it  was  productive  slowly  of 
deep  anesthesia,  accompanied  with  convulsive  rather  than  tetanic  move- 
ments.    Eecovery  was  slow,  as  if  from  deep  intoxication.     Eichardson 


838  ANESTHESIA 

regarded  its  anesthetic  value  as  indifferent.  See  Wachsmuth's  Mixture, 
and  also  Apinol. 

TTdrenin. — A  local  anesthetic  containing  beta-eucain  and  adrenalin. 
According  to  "Riedel's  Mentor,"  1913,  308,  ndrenin  contains,  per  c.  c, 
0.01  gni.  beta-encain  hydrochlorid  and  0.00003  gni.  adrenalin  hydro- 
chlorid  iii  physiological  salt  solution,  with  the  addition  of  0.5  per  cent 
chloretone  as  a  preservative.  This  combination  is  mentioned  by  Cob- 
lentz  ("The  Newer  Eeniedies,"  4th  ed.,  138),  but  he  unmistakably  refers 
to  Eudrenin,  q.  v. 

Urea  Hydrochlorid. — See  Quinin  and  Urea  Hydrochlorid  and  Thi- 
bault's  Local  Ana'sthetic. 

Urethane. — Urethane  (Ethyl  Carbamate;  Ethylurethane), 

/NH2 
C0< 

\OC2HB 

is  well  known  as  possessing  a  rapid  hypnotic  action,  although  not  suffi- 
ciently powerful  for  use  in  cases  where  there  is  pain  or  distress.  Hiib- 
ner  and  Sticker  tried  urethane  on  man,  and  Mairet  and  Combemale  on 
animals,  but  were  unable  to  show  that  it  possessed  a  reliable  hypnotic 
action,  Nerking  and  Schiirmann  {Med.  Klinih,  1908,  No.  46)  subse- 
quently tested  the  preparation  to  ascertain  its  value  as  an  anesthetic, 
assuming  that  urethane  was  split  up  in  the  organism  into  urea  and  the 
ethyl  group.  The  intravenous  application  of  5  to  10  c.  c.  of  a  30  per 
cent  solution  of  urethane  gave  no  positive  result  in  rabbits,  and  it  con- 
sequently seemed  doubtful  whether  anesthesia  could  be  obtained  by  the 
aid  of  urethane  alone.  Satisfactory  results  were  obtained,  however, 
with  the  combination  of  urethane  and  chloral  hydrate.  Nerking  and 
Schiirmann  used  a  30  per  cent  solution  of  urethane  and  a  solution  of 
chloral  hydrate  5:10,  suitable  doses  being  injected  intravenously.  These 
trials  effected  a  quiet,  safe  anesthesia,  with  complete  abolition  of  sensa- 
tion; but  so  far,  to  our  knowledge,  trials  of  this  method  have  not  been 
made  on  man.  Hauckold  {Z.  f.  exper.  Path.  u.  Therap.,  1910,  7,  No. 
3,  743)  studied  the  effect  of  scopolamin  on  the  action  of  urethane,  and 
ascertained  by  experiments  that  scopolamin,  which  does  not  by  itself 
produce  anesthesia  in  rabbits,  had  a  considerable  effect  in  enhancing  the 
anesthetic  properties  of  urethane.  Small  quantities  of  urethane,  which 
would  not  by  themselves  produce  anesthesia,  showed  a  narcotic  action 
by  means  of  a  minimal  dose  of  scopolamin.  The  latter  was  also  found 
to  possess  a  similar  action  in  combination  with  morphin. 

TJrosemin. — This  local  anesthetic  is  a  1  per  cent  solution  of  uric 
acid  in  3  c.  c.  of  water,  with  the  addition  of  1  c.  c.  of  Ensemin  (q.  v.), 
and  0.00005  gm.  of  adrenalin  hydrochlorid. 

On  urosemin,  see  Mannich  and  Schwedes:  Apoth.-Ztg.,  1913,  351; 
Wolfer:   Med.  Klinik,  1913,  1581. 


A   LIST    OF    ANESTHETICS  839 

Valerene. — See  Amylene. 

Vanodrin. — This  dental  anesthetic  contains  0.015  gm.  novocain  and 
0.0001  gm.  adrenalin  liydrochlorid  in  1  c.  c. 

Vienna  Anesthetic. — A  mixture  of  alcohol,  13  parts  by  weight; 
chloroform,  77  parts  by  weight;  and  ether,  11  parts  by  weight. 

Vienna  Elizabeth  Hospital  Mixture. — See  Wertheim's  Mixture. 

Vienna  General  Hospital  Mixture. — Alcohol,  9  parts;  chloroform, 
30  parts ;  and  ether,  9  parts.  On  this  mixture,  see  Potter :  "Mat.  Med. 
Pharm.  and  Therap.,"  10th  ed.,  88. 

Vienna  Mixture. — A  mixture,  introduced  about  1856,  of  8  parts 
of  ether  and  1  part  of  chloroform  in  hot  weather;  and  6  parts  of  ether 
and  3  parts  of  chloroform  in  cold  weather.  See  Sci.  Am.  Suppl.,  No. 
516;  also,  Eichardson:  "Asclepiad,"  1885,  274.  According  to  Hewitt 
"Anassthetics  and  Their  Administration,"  3rd  ed.,  '^^Q),  Vienna  mixture 
is  composed  of  chloroform,  1  part,  and  ether,  3  parts.  According  to 
Miiller  ("Narkologie,"  492),  Vienna  mixture  is  composed  of  chloroform 
3  parts  and  ether  1  part. 

Viferral. — See  Polychloral. 

Vinyl  Trichlorid. — See  Ethylene   (monochloro-)  Chlorid. 

Vinyldiacetonalkamin. — Schering  (Eng.  Pat.,  20,697,  1896)  claimed 
that  the  vinyldiacetonalkamin  of  Fischer  was  a  mixture  of  two  bases, 
and  that  its  derivatives  might  be  employed  as  anesthetics. 

Wachsmuth's  Mixture. — A  mixture  of  chloroform,  4  parts,  and 
oleum  terebinth.,  1  part.  "To  prevent  syncope."  Miiller,  "Narkologie," 
1,  493.     See  Turpentine,  and  cf.  Apinol. 

Waite's  lokaler  Schmerztoter. — An  anesthetic  for  minor  operations, 
said  to  be  a  water  solution  of  cocain,  iodin,  thymol,  and  glycerin,  con- 
taining only  cocain  and  creosote  in  glycerinized  water  (Gehe's  Codex, 
Nov.,  1910,  382). 

Water. — On  water  as  a  local  anesthetic,  see  Wyeth :  N.  Y.  Med.  J., 
Jan.  6,  1906.  Water  has  been  employed  as  a  local  anesthetic  (pressure 
anesthesia)  in  dentistry  and  in  certain  minor  surgical  cases.  It  is  no 
doubt  true  that  the  anesthetic  action  of  certain  compounds  is  solely 
attributable  to  the  pressure  anesthesia  produced  by  hypodermic  injec- 
tion of  the  solution. 

Welt-Anaesthetikum  (Universal  Anesthetic). — A  dental  local  anes- 
thetic containing  adrenalin  hydrochlorid,  sodium  chlorid,  chloretone, 
cocain  hydrochlorid,  menthol,  eucalyptol,  and  distilled  water. 

Wertheim's  Mixture. — This  is  a  mixture  of  chloroform,  1  part;  ethyl 
ether,  2  parts;  and  benzin  or  canadol,  1  part.  It  is  a  modification  of 
Schleich's  mixture  and  is  often  referred  to  as  Vienna  Elizabeth  Hos- 
pital Mixture.  Wertheim's  solution  or  mixture  was  used  by  Williams 
{Trans.  Soc.  Anesth.,  ^  98).  Silk's  experience  {Hid.,  5,  138)  led  him 
to  believe  that  the  petroleum  ether  contained  in  it  was  inoperative,  so 


840  ANESTHESIA 

that  the  solution  was  practically  one  of  ether  and  chloroform.  As  such 
he  considered  that  it  had  some  merits. 

"Westron." — See  TetracMorethane. 

Wigger's  Anesthetic  Ether. — See  Ethyl  Chlorid  PolychI orated. 

Wilson's  Local  Anesthetic. — A  water  solution,  of  which  100  parts 
contain  7.5  per  cent  alcohol,  0.05  per  cent  boric  acid,  0.05  per  cent  ben- 
zoic acid,  0.75  per  cent  cocain  hydrochlorid,  1.0  per  cent  nitroglycerin 
solution  (1:100),  0.05  per  cent  naphthol,  and  2  drops  of  a  mixture  of 
equal  parts  of  oils  of  eucalyptus,  peppermint,  gaultheria,  and  thyme. 

Yohimbin. — This  is  claimed  to  be  a  local  anesthetic  for  eye  and 
nose  practice.  It  is,  however,  best  known  as  an  aphrodisiac.  Yohimbin 
hydrochlorid  (CaaHggOsHo.HCl)  is  a  white  crystalline  powder,  having 
a  melting  point  of  +  288-290°  C.  For  a  full  study  of  the  pharmaco- 
dynamic properties  of  yohimbin,  see  Mtiller :  Archives  internat.  d.  phar~ 
macol.  et  d.  therap.,  1907,  65;  Archiv  f.  Anat.  und  Physiol.^  1907,  391; 
Franz:  Med.  Klinih,  1907,  No.  34,  1027.  Miiller  showed  that  the  action 
of  yohimbin  depended  chiefly  on  its  influence  on  the  walls  of  the  ves- 
sels, and  that,  even  when  applied  locally,  the  action  was  vasodilating 
and  anesthetic.  Large  doses  were  found  to  produce  a  continued  fall  of 
blood  pressure,  and  lethal  ones  to  paralyze  the  heart  also  by  injuring 
the  cardiac  muscle.  Holterbach  (Berl.  tierdrztl.  Woch.,  1907,  No.  32 ; 
Beut.  tierdrztl.  Woch.,  1907,  Nos.  13  and  14)  points  out  that  the  anes- 
thetic action  of  yohimbin  may  be  said  to  be  recognized.  On  the  com- 
parative effects  of  yohimbin,  protoveratrin,  and  veratrin  on  isolated 
muscle  and  nerve,  see  Waller:  Proc.  Physiol.  Soc,  1910,  xi-xiv;  J.  Phy- 
siol., 41,  xi. 

On  the  anesthetic  action  of  yohimbin,  see  the  following  papers : 

Lowy  and  Miiller :  "Zur  Kenntnis  der  anasthesierenden  Wirkung  des 
Yohimbin,"  Miinch.  med.  Woch.,  1903,  No.  15. 

Magnani:  "Zur  anasthesierenden  Wirkung  des  Yohimbin,"  ibid., 
1903,  No.  5. 

Magnani:  "Un  nuovo  alcaloide  anestetizzante  la  congiunctiva  e  la 
cornea,"  La  clinica  moderna,  1902,  No.  35. 

Oberwarth :    "Ueber  Yohimbin,"  Virchows  Archiv,  153,  292. 

Yohydrol. — "Yohydrol"  is  a  proprietary  name  for  a  Yohimbin  Hy- 
drochlorid {q.  V.)  of  German  manufacture. 

Zeuner's  Halspastillen ;  Zeuner's  Hustenpastillen.  These  contain 
Anesthesin  (q.  v.). 

Zykloform. — See  Cycloform. 


CHAPTER    XXI 

STATISTICS 

Introduction, 

Collateral  Information  :  Local  Anesthesia ;  Nitrous  Oxid  Alone 
or  with  Air;  Nitrous  Oxid  with  Oxygen;  Anesthol-Ether  Sequence; 
Chloroform-Ether  Sequence;  Nitrous  Oxid-Ether  Sequence;  Anesthol; 
Ether,  Drop  or  Vapor;  Ethyl  Chlorid-Ether  Sequence;  Ethyl  Chlorid; 
Chloroform-Oxygen;  Chloroform,  Drop  or  Vapor;  Intratracheal  Anes- 
thesia ;  Oil  of  Bitter  Orange  Peel-Ether  Sequence ;  Comparison  of  Amer- 
ican Statistics  for  1905-1911'  with  Those  for  1892 ;  Comparison  of  Amer- 
ican with  European  Statistics;  American  Statistics,  1905-1912,  Inc. 

Conclusions. 

INTRODUCTION 

In  March  of  1911,  circulars  were  sent  out  to  all  the  puhlic 
hospitals  with  not  less  than  ten  beds  in  the  United  States,  Canada, 
Cuba,  and  the  Canal  Zone.  Ninety-nine  hospitals,  widely  separated 
(in  forty  States,  Canada,  and  the  Canal  Zone),  furnished  the  facts  on 
which  these  statistics  are  based.  The  data  given  by  these  ninety-nine 
hospitals  may  be  considered  as  fairly  representative  of  statistics  from 
American  hospitals  in  general.  In  New  York  City  two  large  hospitals 
(St.  Luke's  Hospital  and  the  German  Hospital)  had  statistics  from 
an  anesthetic  standpoint  immediately  available.  We  feel  that  hospital 
administration  should  require  that  accurate  data  as  to  the  anesthetics 
used  should  be  kept  on  file,  as  well  as  other  information. 

The  Army  and  Navy  officials  sent  replies  by  return  mail,  showing 
that  these  statistics  are  kept  on  file  as  are  others. 

A  careful  study  of  the  Army  and  Navy  statistics  will  amply  repay 
one.     (Page  842.) 

It  is  a  remarkable  fact  that  the  only  two  fatalities  that  occurred 
in  the  naval  service  were  under  ether. 

The  location  of  the  four  chloroform  fatalities  mentioned  in  Table  2 
is  unknown. 

The  third  table  on  page  843  includes  the  Army  and  Navy  statistics. 
The  anesthetics  are  placed  according  to  their  value  as  regards  life.    The 

841 


842  ANESTHESIA 

TABLE  1.— The  United  States  Navy  for  the  Years  1908-1910 


Anesthetic 


Ether 

Ether  (rectal) 

Ether,  morphin  and  scopolamin 

Ether  and  nitrous  oxid 

Ether  and  chloroform 

Ethyl  chlorid  (general) 

Ethyl  chlorid  and  ether 

Ethyl  chlorid  and  chloroform.  . 

Chloroform 

Cocain 

Cocain  and  ethyl  chlorid  (local) 

Cocain  and  epinephrin 

Beta-eucain  and  epinephrin 

Eucain 

Novocain 

Novocain  and  epinephrin 

Schleich's  solution  No.  2 

Total 


Number 


2,218 
2 

40 

140 

2 

16 

24 

2 

365 

91 
3 
3 
4 
1 
4 
4 
2 


2,921 


Deaths 


TABLE  2. — Anesthetics  Used  in  Surgical  Operations  Performed  on 
Officers  and  Enlisted  Men  of  the  Army  for  the  Years  1904-1910 


Year 

Chloro- 
form 

No. 

Ether  No. 

Chloroform 
and  Ether 

No. 

Spinal  No.  ^ 

Local  No. 

1904 

835 
713 
684 
571 
497 
335 
296 

878 
806 
861 
831 
965 
1,326 
1,513 

"83 
73 
37 
67 

100 
55 

"eo 

"29 
9 

1,096 

1905 

1,070 

1906 

1,234 

1907 

1,270 

1908 

1,652 

1909 

1,873 

1910 

1,793 

Total 

3,931 

7,180 

415 

98 

9,988 

^  The  agents  used  in  spinal  analgesia  were  tropacocain  and  beta  eucain. 
Four  deaths  were  due  to  the  anesthetic  (chloroform)  in  all  the  cases. 


number  to  the  left  of  each  anesthetic  refers  to  the  relative  frequency  of 
their  administration. 

These  statistics  speak  for  themselves.  The  following  remarks  are 
based  upon  collateral  information  obtained  with  the  numerical  data. 

The  total  number  of  administrations  from  the  ninety-nine  hospitals 
was  278,945. 


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844  ANESTHESIA 


COLLATERAL    INFORMATION 

Local  Anesthesia. — It  will  be  noted  that  local  anesthesia  is  first  in 
the  list,  with  a  total  of  14,878  administrations  with  no  deaths.  It  is 
safe  to  presume  that  very  few  of  these  were  for  major  operations.  We 
have  knowledge  of  two  deaths  from  local  anesthesia,  both  occurring  in 
private  practice.  In  one  case,  a  laparotomy,  the  patient  died  of  pneu- 
monia within  four  days  of  the  operation;  in  the  second,  external  ure- 
throtomy, the  patient  died  from  psychic  shock..  The  latter  accident  was 
an  avoidable  one.  If  the  patient  had  been  properly  prepared,  and  had 
been  given  a  preliminary  hypodermic  of  morphin,  the  psychic  element 
would  in  all  probability  have  been  removed. 

Local  anesthesia  deserves  more  consideration,  both  for  major  and 
minor  operations. 

Nitrous  Oxid  Alone  or  with  Air. — ISTine-tenths  of  the  small  mor- 
tality under  nitrous  oxid  has  occurred  when  the  gas  was  administered 
either  alone  or  diluted  with  air.  Hewitt  gives  a  list  of  thirty  reported 
deaths  between  1860  and  1900.  ISTo  statistics  are  to  be  had  as  to  the 
number  of  administrations  during  that  time,  but  the  proportion  of 
deaths  is  given  by  different  writers  as  from  one  in  100,000  to  one  iu 
500,000.  We  are  inclined  to  believe  that  both  of  these  estimates  are 
wrong.  One  death  in  20,000  would  be  more  nearly  correct.  Even  if 
this  statement  is  true,  it  would  still  make  nitrous  oxid  the  safest,  pul- 
monary anesthetic  now  in  general  use.  All  deaths  noted  were  reported 
as  resulting  from  asphyxiation,  the  patient  exhibiting  some  one  of  the 
following  characteristics:  (1)  Narrowed  air  passages  by  enlarged  ton- 
sils, deformed  jaw,  or  fixed  morbid  growth.  (2)  Very  strong,  having 
good  muscular  control.  (3)  Obesity,  or  enlarged,  fixed  tongue  or  uvula. 
(4)  Alcoholic. 

Twenty-two  of  the  thirty  were  dental  operations  and  four  surgical. 
The  other  cases  were  indefinite.  All  of  these  patients  were  predisposed 
to  asphyxial  symptoms.  The  athletic  alcoholic  is  the  most  difficult  of 
all  patients  with  this  form  of  anesthesia. 

Nitrous  Oxid  with  Oxygen. — ISltrous  oxid  with  oxygen  has  8,585 
administrations  in  the  foregoing  table,  with  no  deaths.  This  combina- 
tion rightfully  holds  its  place  as  the  safest  of  all  pulmonary  anesthetics, 
not  only  according  to  American  statistics,  but  also  in  all  other  available 
statistics.  That  it  is  not  totally  devoid  of  danger  is  attested  by  the 
deaths  following  its  administration  reported  from  time  to  time  in  the 
medical  press. 

The  statistics  for  dental  administrations  should  not  be  combined 
with  those  of  general  surgery.  We  have  no  hesitation  in  stating  that 
one  death  in  a  million  cases,  as  reported  by  Hare,  will  not  hold  for 


STATISTICS  845 

surgical  cases.  One  death  in  ten  thousand  is  a  fair  estimate  for  this 
combination  in  America. 

While  nitrous  oxid  with  oxygen  is  unquestionably  the  safest  anes- 
thetic now  known,  the  only  likelihood  of  death  being  by  asphyxiation, 
yet  there  are  patients  who  will  reach  the  asphyxial  stage  before  reach- 
ing surgical  anesthesia;  or,  surgical  anesthesia  having  been  induced, 
the  asphyxial  point  is  so  very  near  the  plane  of  surgical  anesthesia  that, 
with  some  subjects,  it  is  an  ever-present  danger.  The  same  patients 
that  are  pronounced  difficult  or  dangerous  with  nitrous  oxid  and  air, 
while  easier  to  anesthetize  with  nitrous  oxid  and  oxygen,  form  the  most 
dangerous  and  difficult  class  of  patients  for  this  combination. 

No  deaths  attributable  to  the  anesthetic  were  reported  for  a  long 
while,  but  as  nitrous  oxid  and  oxygen  became  more  commonly  used  for 
long  operations,  deaths  have  been  and  are  being  reported  from  time  to 
time.  Unfortunately,  surgeons  and  anesthetists  make  use  of  this  anes- 
thetic without  studying  its  previous  history,  its  peculiarities,  indica- 
tions, and  contraindications.  It  is  known  that  few  surgeons  have  the 
courage  to  report  deaths  under  anesthesia,  especially  those  occurring  in 
private  practice.  This  was  not  the  case  with  Lydston,^  of  Chicago,  who 
made  the  first  report  of  death  by  nitrous  oxid  and  oxygen.  The  mis- 
takes in  this  case  should  be  helpful  in  enabling  others  to  avoid  similar 
errors  in  the  future. 

The  first  mistake  was  in  not  giving  preliminary  medication. 

The  second,  in  commencing  the  operation  before  full  surgical  anes- 
thesia had  been  established  long  enough  to  insure  obtunding  of  the  refiex 
mechanism. 

The  third,  in  the  surgeon  or  anesthetist  not  being  prepared  for  a 
tracheotomy  in  case  of  accident. 

The  following  case  is  reported  by  Teter.  He  gives  a  detailed  report 
showing  that  the  anesthetic  was  not  the  primary  cause  of  death,  but,  if 
the  theories  of  Yandell  Henderson  and  Gatch  are  correct,  this  death 
may  have  been  due  to  too  much  aeration  of  the  lungs. 

"Case  7.  Patient — Mrs.  M.,  aged  60,  had  been  vomiting  for  over  a 
month  and  was  in  an  exhausted  condition  from  starvation.  The  cause 
of  her  trouble  was  very  obscure  and  symptoms  were  lacking.  Gall-stones 
were  finally  diagnosed.  Owing  to  her  extremely  exhausted  condition  an 
operation  was  considered  hazardous  but  imperative.  The  persons  inter- 
ested were  aware  of  the  likelihood  of  a  fatal  termination,  so  were  pre- 
pared in  a  way  for  what  followed.  I  found  a  very  weak,  thready,  ir- 
regular pulse,  running  at  the  rate  of  150,  and  hardly  perceptible  in  the 
radial  artery. 

"Anesthesia.  The  anesthetic  was  started  with  95  parts  nitrous  oxid 
and  5  parts  oxygen.     The  oxygen  was  increased  rapidly  up  to  10  parts. 

^Lydston,  Frank:  Med.  Bee,  Nov.  12,  1910;  Feb.  11,  1911. 


846  ANESTHESIA 

The  patient  was  found  to  be  fully  anesthetized  after  she  had  taken  about 
eight  inhalations.  It  was  necessary  to  increase  the  oxygen  to  30  parts 
or  more  to  prevent  too  deep  anesthesia.  There  was  a  peculiar  livid  ap- 
pearance in  the  face,  but  there  was  no  cyanosis  or  any  indication  of 
anoxemia.  The  respiration  being  unhampered  and  regular,  the  pulse 
was  about  as  rapid  as  at  the  beginning,  but  was  of  better  tension  and 
more  regular. 

"Operation.  This  was  begun  within  two  minutes.  There  was  no 
noticeable  alteration  in  either  respiration  or  circulation  when  the  in- 
cision was  made.  The  corneal  reflex  was  abolished  from  the  time  anes- 
thesia was  noticed  to  be  present.  It  was  necessary  to  increase  the  oxygen 
and  diminish  the  nitrous  oxid  greatly  to  prevent  an  overdose  of  the 
anesthetic.  By  the  continued  application  of  the  phonendoscope  the 
heart  was  found  to  be  acting  fairly  well.  Everything  was  going  along 
nicely  until  work  was  begun  in  the  cystic  duct  and  gall  bladder;  then 
respiration  became  uneven  and  forced,  and  the  heart  sounds  were  barely 
discernible.  The  operation  had  been  in  progress  for  fifty-five  minutes. 
There  was  no  cyanosis  present  in  the  face  and  oxygenation  seemed  to 
be  perfect,  but  it  was  noticed  that  the  fingers  of  the  patient  were  blue. 
This  blueness  gradually  crept  up  the  hands  and  arms,  and  as  a  large 
increase  of  oxygen  and  the  discontinuance  of  the  nitrous  oxid  did  not 
remedy  the  condition,  we  at  once  used  pure  oxygen,  atropin,  strychnin, 
but  with  no  results,  as  the  pulse  and  respiration  ceased. 

"Artificial  respiration  and  lung  inflation  with  pure  oxygen  and  other 
resuscitating  measures  were  carried  out  for  forty  minutes  without  a  sign 
of  reanimation.  This  death  was  due  to  shock  and  primary  cardiac  fail- 
ure. The  anesthetic  was  blamable  only  in  so  far  as  it  added  its  in- 
fluence in  bringing  about  a  lower  resistance  of  the  organism."' 

Crile  reported  one  death  (the  third)  six  hours  after  the  operation, 
and  attributed  the  death  partly  to  the  anesthetic  and  partly  to  im- 
perfect technique  and  administration. 

The  fourth  case  was  reported  from  Johns  Hopkins  University. 

One  of  the  authors  was  told  of  a  death  occurring  when  nitrous  oxid 
was  administered  by  a  reliable  dentist  in  New  York  City,  but  in  such  a 
way  that  it  is  impossible  to  make  a  detailed  report  upon  this  case. 

Unquestionably  deaths  occur  under  this  anesthetic,  as  with  others, 
that  are  never  reported.  These  statistics  are  compiled  only  from  re- 
liable data  given  from  hospitals. 

Albert  Miller,  of  Providence,  E.  I.,  has  collected  references  to 
eighteen  deaths  under  nitrous  oxid  with  oxygen.  The  list  given  below 
includes  those  Just  reviewed : 

Teter:  "Shock  and  Primary  Cardiac  Failure,"  /.  Am.  Med.  Assn., 
Aug.  7,  1909,  643;  Crile:  "Myocarditis,  Six  Hours  after  Operation," 
Soutliern  Med.  J.,  Jan.,  1910,  29;  Lydston:     "Anesthetic,"  Med.  Bee, 


STATISTICS  847 

Nov.  12,  1910,  86G ;  Allen :  "Uremia,"  Boston  Med.  and  Surg.  J.,  Oct. 
19,  1911,  589;  Allen:  Ihid.,  no  details;  Gateh:  "Hyperthyroidism,"  J. 
Am.  Med.  Assn.,  Xov.  11,  1911,  1593;  Gatch:  "Pericardial  Effusion," 
Ihid.;  Gatch:  "Lymphatic  Diathesis,"  Ihid.;  Olow:^  "Diseased  Arter- 
ies," Beitr.  hlin.  Chir.,  Dec,  1911;  Boys:  "Anesthetic,"  Burg.  Gynec. 
and  Ohsiet.,  Apr.,  1912,  388;  Miller:  "Suffocation  from  Inspired  Vom- 
itus,"  J.  Am.  Med.  Ass7i.,  Nov.  23,  1912,  1847;  Flagg:  "Anesthetic," 
N.  Y.  J.  Med.,  Nov.,  1912;  Teter:  "Impure  Gas,"  J.  Am.  Med.  Assn., 
Nov.  23,  1912,  1861 ;  Salzer :  "Anesthetic,"  J.  Am.  Med.  Assn.,  Nov.  23, 
1912,  1872;  Collins:  "Impure  Gas,"  J.  Am.  Med.  Assn.,  Nov.  23,  1912, 
1862;  Buchanan:  "Anesthetic,"  J.  Am.  Med.  Assn.,  Nov.  23,  1912, 
1860. 

Anesthol-Ether  Sequence. — Anesthol-ether  is  the  next  safest  com- 
bination, no  deaths  being  recorded  in  3,827  administrations. 

Chloroform-Ether  Sequence. — Chloroform-ether  comes  next  in  the 
point  of  safety,  having  one  death  in  8,027  administrations. 

As  these  two  sequences  are  practically  identical,  we  will  consider 
them  together. 

Anesthol-Ether  and  Chloroform-Ether  Sequences. — The  anesthol- 
ether  statistics  were  taken  principally  from  the  German  Hospital,  in 
New  York  City,  where  morphin  and  atropin,  or  some  similar  combina- 
tion, is  administered.  The  fact  that  59  per  cent  of  the  hospitals  in  the 
United  States  give  preliminary  medication  before  all  anesthesias  sug- 
gests the  possibility  that  the  majority  of  the  chloroform-ether  anes- 
thesias reported  were  preceded  by  morphin  also.  This  preliminary 
medication  is  here  an  important  point.  It  is  a  factor  of  safety  that 
should  never  be  omitted  when  the  anesthesia  is  started  in  this  way.  If 
we  precede  the  anesthol  or  chloroform  with  a  few  drops  of  the  oil  of 
orange,  as  outlined  in  the  practical  part  of  this  volume,  another  factor 
of  safety  is  added.  That  these  two  sequences  are  so  comparatively  safe, 
is  readily  understood  when  the  physiology  of  this  method  of  initiation 
is  considered.  Bearing  in  mind  the  two  factors  of  safety  just  mentioned, 
and  continuing  the  narcosis  drop  by  drop,  the  blood  pressure  and  pulse 
are  kept  more  nearly  normal  than  when  the  nitrous  oxid-ether  sequence 
or  ether  by  the  drop  is  used. 

When  the  excitement  stage  (which  should  be  evidenced  only  by  deep 
breathing)   is  passed,  a  switch  being  then  made  to  ether  by  the  open 

^  The  case  reported  by  Olow  in  Beitr.  s.  Jclin.  Chir.,  Dec,  1911,  seems  to  have 
been  reported  by  him  again  as  another  case  in  Surg.  Gynec.  and  Obstet.,  April, 
1912.  Of  the  other  cases  to  which  he  refers  in  the  same  article,  that  of  Adams 
(Lancet,  Mar.  24,  1894)  is  included  in  Hewitt 's  list  of  deaths  under  nitrous  oxid 
(" Anaesthetics,"  2nd  ed.,  228,  Case  10),  and  that  of  Owen  {Brit.  Med.  J.,  Dec. 
17,  1914)  was  a  death  under  nitrous  oxid  for  a  dental  operation,  and  not  under 
nitrous  oxid  with  oxygen. 


848  ANESTHESIA 

drop  method,  there  is  very  little  likelihood  of  plunging  the  patient  into 
the  danger  zone^,  and  it  is  a  comparatively  easy  matter  to  maintain  an 
even  plane  after  anesthesia  is  induced  in  the  manner  outlined. 

Nitrous  Oxid-Ether  Sequence. — The  nitrous  oxid-ether  sequence 
comes  next  with  one  death  in  6,905  cases.  While  both  blood  pressure 
and  pulse  are  enormously  raised  with  this  method  of  initiation,  the 
principal  danger  seems  to  be  from  asphyxia.  In  the  hands  of  one  who 
has  acquired  the  technique,  and  in  selected  cases,  it  is  an  ideal  initiatory 
anesthetic.  In  the  hands  of  inexperienced  internes,  and  as  a  routine, 
it  is  not  a  pleasant  sight  to  witness. 

Anesthol. — While  anesthol  is  comparatively  safe,  as  shown  by  the 
table,  it  is  being  rapidly  discarded  as  the  terminal  anesthetic.  The 
physiological  action  of  both  chloroform  and  ethyl  chlorid  upon  the  tis- 
sues fully  warrants  this. 

Ether,  Drop  or  Vapor. — Ether,  drop  or  vapor  (principally  drop), 
while  coming  next  in  point  of  safety  with  one  death  in  5,623  adminis- 
trations, is  first  in  the  total  number  of  administration. 

When  we  consider  these  two  factors,  together  with  the  rapid  and 
steady  increase  in  its  administration  and  its  wider  latitude  of  safety  as 
compared  with  all  other  anesthetics,  we  are  justified  in  stating  that  if 
other  anesthetics  were  used  proportionately  and  as  indiscriminately  this 
anesthetic  would  probably  take  the  first  place  as  regards  immediate 
safety. 

Ethyl  Chlorid-Ether  Sequence. — The  ethyl  chlorid-ether  sequence 
comes  next  with  one  death  in  4,331  administrations.  The  use  of  this 
sequence  is  on  the  increase,  but  it  showed  a  slight  loss  from  1910  to  1911. 
It  does  not  compare  in  point  of  safety  with  the  nitrous  oxid-ether  se- 
quence, according  to  these  figures,  and  yet  it  is  almost  unanimously  con- 
ceded to  be  safer  for  children  than  "gas-ether." 

Ethyl  Chlorid. — The  statistics  of  ethyl  chlorid,  used  alone,  present 
widely  divergent  figures.  One  author  gives  the  death  rate  as  1  in  17,000 
administrations,  another  as  1  in  12,000,  while  others,  reporting  "con- 
siderable experience,"  have  seen  no  deaths  from  its  use.  No  one  places 
this  agent  above  nitrous  oxid  in  safety;  many  question  its  rank  as  com- 
pared with  ether  and  chloroform;  while  others  enthusiastically  predict 
the  displacement  of  the  two  last-named  agents  by  ethyl  chlorid  for  long 
surgical  operations. 

Perhaps  the  most  formidable  array  of  figures  concerning  ethyl 
chlorid  are  the  statistics  compiled  by  Wood,^  covering  over  51,507  cases, 
with  a  mortality  of  1  in  5,710.  In  statistics  covering  over  1,000,000 
cases.  Wood  found  a  mortality  of  1  in  15,000  with  ether,  and  1  in  3,000 
with  chloroform.  If  these  statistics  are  accepted,  ethyl  chlorid  falls 
between  chloroform  and  ether.     Wood  considers  ethyl  chlorid  as  being 

'Wood,  A.  C:  J.  Am.  Med.  Assn.,  1910,  55,  2229. 


STATISTICS 


849 


two  hundred  times  as  dangerous  as  nitrous  oxid^,  this  estimate  being 
based  upon  the  statistics  of  nitrous  oxid,  which  are  given  as  1  death  in 
1,000,000  cases.  This  computation,  doubtless  based  largely  upon  the 
use  of  nitrous  oxid  in  dentistry,  thus  involving  a  much  larger  propor- 
tion of  very  short  operations  than  enters  into  the  estimates  of  others, 
cannot  be  accepted  at  the  present  time  as  a  ba^is  of  comparison  with 
ethyl  chlorid  used  for  both  dental  and  surgical  operations.  The  prob- 
able death  rate  for  nitrous  oxid  and  oxygen  for  surgical  cases  (conceded 
to  be  safer  than  nitrous  oxid  alone)  is  1  in  10,000,  this  rate  being  fixed 
from  the  number  of  deaths  reported  to  the  authors. 

Peterka  ^  collected  from  the  literature  the  following  figures  concern- 
ing the  use  of  ethyl  chlorid: 


Haeker 11,000 

Malherbe 5,248 

Herrenknecht   3,000 

Eotel 5,575 

Ware   12,436 

Seitz    15,150 

Grobon    16,000 

McCardie    3,620 

Paris 5,000 

Benn  2,000 

Reboul  1,500 

Elhs  Morgan    1,000 

Stieda  &  Zander 1,000 

Krupp's  Dental  Clinics . . .  1,500 

Eoux 1,000 

Camns 1,500 

Novi  Losserand 2,000 

Van  Stockum   3,000 

Barton 2,000 

Luke   2,000 

Hornsbrook 800 


Mather  Sill 500 

Neuenborn   400 

Kulenkampff    200 

Behr 300 

Lotheissen 500 

Lop    420 

Murray   150 

Bad  Hall  and  S.  Pelagio.  .  286 

Daniell    100 

Pollosom 200 

Bossart    200 

Severeann 100 

Vicol   109 

Stepinoki 170 

Brodtbuk 550 

Billeter   150 

Helsted   120 

Chaminade 200 

Eabejac 300 

Varia 687 

Total 100,971 


Dividing  the  collected  figure  of  100,971  narcoses  by  the  nine  deaths 
contained  therein,  these  narcoses  yield  a  mortality  rate  of  1 :11,219.  In- 
cluding the  five  deaths  reported  as  occurring  in  the  Graz  clinics,  the  fig- 
ure amounts  to  1  in  8,414. 

^Peterka,  H. :  "Die  Aethylchlorid-bei   (?)  Kelennarkose. "     Bruns'  Beitr.  zur 
Tclin.  CUr.,  81,  436,  1912. 


850 


ANESTHESIA 


Estimated   Mortality-Eate   from   Ethtl-Chlorid   as   a   General 
Anesthetic   (A.  H.  Miller)  ^ 


Observer 
Hare  .... 
McCardie  . 

Luke 

Hewitt  . . . 
McCardie  . 
Ware    .... 


l.in 
1  in 
1  in 
1  in 
1  in 


Death- 
Eate 
3,000 
3,000 
8,000 
10,000 
10,000 


Observer 
Lotheissen 
Ware    .... 

Seitz 

Lotheissen 
Luke  


m 
in 
in 
in 
in 


Death- 
Eate 
12,000 
12,436 
16,000 
17,000 
36,000 


1  in     11,207      Luke 1  in  150,000 


Series  op  Ethyl-Chlorid  Anesthesias  Eeported  from  Personal 
Knowledge^  (A.  H.  Miller) 


Observer 


Cases     Deaths 


SouUier 8,417  0 

Lotheissen 2,550  1 

Ware  2,000  0 

Cumston 197  0 

Newman   1,867  1 

Koenig 40  0 

Malherbe 170  0 

Wiesmer    400  0 

Allen 60  0 

Murray   350  0 

McCardie 1,000  0 

Barton 200  0 


Observer  Cases 

Luke   2,000 

Tuttle 230 

Herrenknecht  . . .  3,000 

Leightou  .......  79 

Greene 12,000 

Lee 5,575 

Dodge   300 

Webster 1,880 

Miller 6,648 

Hornabrook 3,500 

Stieda  and  Zander  1,000 


Deaths 
0 
0 
0 
0 
0 
1 
0 
0 

1 

0 
0 


Total 53,463         4 

*Eead  in  the  Symposium  on  Anesthesia  in  the  Sections  on  Pharmacology  and 
Therapeutics  and  Pathology  and  Physiology  of  the  American  Medical  Association, 
at  the  Sixty-Third  Annual  Session  held  at  Atlantic  City,  June,  1912;  J.  Am.  Med. 
Assn.,  59,  1847. 

^  References : 

Soullier:    Bull  med.,  Paris,  1895,  417. 

Buxton :     ' '  Anaesthetics, ' '  Blakiston,  1900,  297. 

McCardie:    Birmingham  Med.  Eev.,  Jan.,  1900. 

Hewitt:     " Anajsthetics, "  Macmillan,  1901,  228,  384. 

Seitz:    Cor.-Bl.  f.  schweiz.  Aerzie,  1901. 

McCardie:    Lancet,  London,  March  9,  1901,  698. 

Ware:    Med.  Hec.,  Apr.  6,  1901,  533. 

Ware:    Med.  News,  Aug.  3,  1901,  168, 

Chaldecott:    Lancet,  London,  Sept.  13,  1902,  743. 

Anesthetic  Society:    Brit.  Med.  J.,  Nov.  22,  1902,  1654. 

Ware:    J.  Am.  Med.  Assn.,  Nov.  8,  1902,  1160.  (Continued  on  p.  851) 


STATISTICS  851 

Chloroform-Oxygen. — Chloroform-oxygen  comes  next  with  one 
death  in  4,009  operations.  It  is  safe  to  conclude  that  all  of  these  were 
major  cases,  as  this  combination  is  seldom  used  for  short  operations. 
The  use  of  this  combination  is  Justifiably  on  the  increase. 

Chloroform,  Drop  or  Vapor. — Chloroform,  drop  or  vapor,  is  next 
with  one  death  in  2,048  cases.  A  glance  at  the  table  shows  a  decrease 
in  its  use  from  1910  to  1911  as  a  "straight  anesthetic,"  that  is,  used 
from  start  to  finish,  and  this  is  also  in  conformity  with  laboratory  ex- 
perience and  theoretical  teaching. 

It  is  universally  conceded  that  it  is  unjustifiable  to  draw  conclusions 
from  statistics  of  less  than  1,000  anesthesias.  We  refrain  from  further 
remarks  on  the  comparative  value  of  the  remaining  nineteen  sequences 
and  combinations. 

No  better  illustration  of  the  fact  just  stated  could  be  given  than  the 
nitrous-oxid-ether-chloroform  sequence.  The  statistics  of  the  private 
cases   of   the  professional   anesthetists   who   use   this    combination   are 

{Continued  from  page  85G) 
Cumston:     Boston  Med.  and  Surg.  J.,  Jan.  1,  1903,  12. 
Allen:    Am.  J.  Med.  Sc.,  Dec,  1903,  1014. 
Erdmann:    Med.  Neius,  May  28,  1904,  1024. 
Owen:     Brit.  Med.  J.,    Dec.    17,   1904,   1635. 
Hilliard:    Practitioner,  London,  Feb.,  1905,  203. 
Seelig:    Ann.  Surg.,  Aug.,  1905,  185. 
McCardie:    Lancet,  London,  Oct.  7,  1905,  1023. 
Luke:    Brit.  Dental  J.,  Nov.  1,  1905. 
Murray:    Lancet,  London,  Nov.  25,  1905,  1542. 
McCardie:    Brit.  Med.  J.,  March  17,  1906,  616. 
Luke:    Lancet,  London,  May  5,  1906,  1233. 
Patton:    Anesthetics,  Cleveland  Press,  Chicago,  1906,  159. 
Leighton:    St.  Louis  Med.' Sev.,  Feb.  16,   1907,  158. 
Eugh:    N.  Y.  Med.  J.,  Aug.  10,  1907,  262. 
Barton:    Practitioner,  London,  Sept.,  1907,  391. 
Herrenknecht :     Miinch.  med.  Woch.,  Dec.  3,  1907. 
Gibbon:    Ann.  Surg.,  Nov.,  1908,  795. 

Greene :     Items  of  Interest,  Cons.  Dent.  Mfg.  Co.,  New  York,  Sept.,  1908. 
Lee:    Ann.  Surg.,  Nov.,  1908,  641. 

Dodge:    Boston  Med.  and  Surg.  J.,  Feb.  25,  1909,  234. 
Webster:    Surg.,  Gynec.  and  Obst.,  Apr.,  1909,  402. 
Miller:    Boston  Med.  and  Surg.  J.,  May  20,  1909,  643. 
Teter:    J.  Am.  Med.  Assn.,  Aug.  7,  1909,  451. 
Crile:    Southern  Med.  J.,  Jan.,  1910,  20. 
Allen:    Boston  Med.  and  Surg.  J.,  Oct.  19,  1911,  589. 
Hornabrook:    Australasian  Med.  Gaz.,  Nov.,  1911. 
Gatch:    J.  Am.  Med.  Assn.,  Nov.  11,  1911,  1593. 
Lydston:     Med.  Bee,  Nov.  12,  1910,  866. 
Boys:    Surg.,  Gynec.  and  Ohst.,  Apr.,  1912,  388. 
Olow:    Beitr.  z.  Tclin.  Chir.,  Dec,  1911. 
Stieda  and  Zander:    Med.  Klin.,  Mar.  24,  1912. 
Hare :     ' '  Keen 's  Surgery, ' '  Saunders,  1910,  1038. 


852  ANESTHESIA 

naturally  not  included  in  this  list,  but  that  the  combination  fell  into  bad 
hands  is  observed  from  the  record  of  one  death  in  183  cases. 

Hewitt  ^  states  of  this  sequence  that  he  has  now  employed  it  for 
several  years,  and,  while  admitting  that  it  is  hardly  suitable  for  those 
who  have  had  but  little  experience,  he  confidently  recommends  it  to 
all  others.  ' 

The  senior  author  fully  agrees  with  this  statement,  having  used  it  in 
thousands  of  cases  with  only  the  most  satisfactory  results. 

Statistics  given  for  chloroform  vary  greatly.  Lawrie  ^  reports  30,000 
chloroform  anesthesias  without  a  death.  -In  some  of  the  British  hos- 
pitals the  deaths  are  reported  as  high  as  one  in  250.  The  German  sta- 
tistics give  a  mortality  of  one  in  2,300.  The  statistics  of  Lawrie  quoted 
above  would  confirm  Gwathmey's  experiments  as  regards  temperature  in 
the  administration  of  chloroform. 

Charles  Prevost  Grayson,^  of  Philadelphia,  in  1912  reported  that 
during  the  last  eight  years  he  had  used  it  3,800  times  in  adenoid  and 
tonsil  operations  without  mishaps  of  any  kind. 

The  United  States  Army  reports  four  deaths  in  3,931  operations.  In 
the  statistics  gathered  from  the  different  hospitals  in  the  United  States 
we  have  two  deaths  in  1,311  administrations,  an  average  of  one  in  657 
operations. 

In  the  United  States  Navy  no  deaths  have  occurred  in  365  adminis- 
trations of  chloroform. 

Hewitt  reports  214  deaths  in  676,767  administrations  of  cliloroform, 
making  a  death  rate  of  one  in  3,162. 

Intratracheal  Anesthesia. — The  statistics  of  intratracheal  anes- 
thesia show  that  administrations  by  this  method  ai'e  rapidly  running 
into  the  thousands  and  that  no  recent  deaths  have  been  recorded.  This 
is  now  considered  by  those  whose  judgment  is  impartial  as  an  absolutely 
safe  procedure,  the  four  deaths  reported  under  this  method  being  en- 
tirely avoidable,  and  not  apt  to  be  repeated. 

Oil  of  Bitter  Orange  Peel-Ether  Sequence.* — The  oil  of  bitter 
orange  peel-ether  sequence  by  the  closed  method  (first  accomplished  by 
Woolsey,  of  Brooklyn)  was  an  important  discovery.  It  showed  that  the 
administration  by  the  closed  method  of  a  non-anesthetic  agent  followed 
by  ether,  producing  an  absolutely  safe  anesthesia  while  abolishing  the 
second  stage  of  excitement  entirely,  gives  a  resultant  anesthesia  suffi- 
ciently deep  for  all  surgical  work  requiring  absolute  relaxation. 

'Hewitt:     " Ansesthetics, "  1912,  501. 

''Bull.  Johns  Hopkins  Hosp.,  Jan.,  1895. 

'  At  the  meeting  of  the  American  Laryngological,  Ehinological,  and  Otological 
Society,  1912. 

*  For  a  full  discussion  of  the  use  ©f  the  oil  of  bitter  orange  peel  in  anesthesia, 
see  Chapter  II,   "General  Physiology." 


STATISTICS 


853 


Comparison  of  American  Statistics  for   1905-1911  with  Those  for 

1892. — That  progress  has  been  made  in  America  is  shown  by  comparing 
these  statistics  with  those  gathered  in  1892  as  reported  in  the  tenth 
vohime  of  the  Medico-Legal  Journal  of  that  year. 

Sixty-two  operators  reported  109,196  cases,  with  thirty-nine  fatalities, 
or  one  death  in  approximately  2,800. 


Narcoses 

Deaths 

Ratio 

Chloroform 

94,123 
9,431 
2,891 
1,381 
2,151 
201 

36 

"i 

i 
1 

1-2,614 

Ether 

0-9,431 

Ether  and  Chloroform 

1-2,891 

Ether  and  Alcohol 

1-1,381 

Bromoform  and  Ethyl  Bromid  

1-2,151 

Pental 

1-   201 

110,178 

39 

1-2,825 

Post-mortems  were  held  in  many  of  these  and  in  twenty-five  some 
form  of  cardiac  disease  was  found. 

The  present  statistics  give  one  death  in  approximately  5,000  cases. 
The  safety  to  the  patient  has  almost  doubled  since  1892.  This  compari- 
son would  also  seem  to  show  that  preliminary  medication,  combinations, 
and  sequences  of  anesthetics  are  potent  factors  of  safety. 

Comparison  of  American  with  European  Statistics. — There  seem 
tp  be  no  late  statistics  available.  Hewitt  gives  a  number  gathered  by 
Sir  B.  W.  Eichardson  in  1892  as  follows: 


Adminis- 
trations 

Deaths 

Ratio 

Chloroform 

35,162 
8,431 

11 
1 

1-3,196 

Ether 

1-8,431 

If  we  gather  statistics  according  to  climate,  they  present  an  entirely 
different  aspect.  For  instance,  Dastre  ^  reports  one  death  in  11,448  ad- 
ministrations of  chloroform  during  the  Crimean  War,  and  Lawrie  -  re- 
ports 30,000  chloroform  anesthetizations  without  a  death. 

These  statistics  would  seem  to  support  the  contention  of  the  authors 


^  Dastre:   "Les  Anesthesiques, "  115. 

*  Lawrie:    Bull.  Johns  HopMns  Hosp.,  Jan.,  1895. 


854 


ANESTHESIA 


that  warmth,  when  applied  to  anesthetics,  is  a  distinct  factor  of  safety. 
It  will  thus  be  seen  that  chloroform,  when  given  under  favorable  circum- 
stances, is  equal  to  ether  in  regard  to  immediate  safety. 

If  ive  should  administer  the  chloroform  with  oxygen  in  a  Southern  cli- 
mate the  probability  is  that  we  might  have  an  anesthetic  practically  free 
from  danger.  In  the  Southern  States  chloroform  immediately  rises  in 
value  as  regards  life.  When  chloroform  is  administered  by  a  closed 
method  and  oxygen^  and  rebreathing  is  used  as  in  the  Roth-Drager  ap- 
paratus,  it  seems  to  be  equally  as  safe  as  nitrous  oxid  and  oxygen,  but, 
when  used  in  a  crude  ivay  without  regard  to  rebreathing,  warmth,  and 
moisture,  ether  immediately  rises  in  value  from  2  1/2  to  8  times  the 
safety  of  chloroform. 

By  combining  Juilliard's  and  Ormsby's  statistics,  Hewitt  gives  the 
following  table: 


Anesthetic 

Adminis- 
trations 

Deaths 

Ratio 

Chloroform 

676,767 
407,553 

214 
25 

1-3,162 
1-16,302 

Ether 

"Ether  is,  roughly,  more  than  five  times  as  safe  as  chloroform,"  ac- 
cording to  these  statistics. 

Probyn  Williams  ^  gives  the  following : 


Ether 
1  in  16,000 


Chloroform 
1  in  2,500 


Lnke  and  Eoss  ^  report  twenty-five  deaths  under  nitrous  oxid,  and 
thirty  under  ethyl  chlorid. 

The  statistics  for  1912  are  now  completed.  The  figures  have  been 
combined  with  those  of  1911,  all  duplicates  being  omitted. 

Number  of  States  and  Territories 45 

Not  including 

Manila,  P.  I.,  Halifax,  N.  S.,  Honolulu,  H.  I., 
Montreal,  Quebec,  Cape  Breton,  Ancon,  C.  Z. 

Number  of  Hospitals 386 

The  following  is  the  result : 

American  Statistics  ^ — 1905-1912,  Inc. — The  supplementary  list  of 
439  "experiments'^  follows: 

*  Williams,  Probyn:  "A  Practical  Guide  to  the  Administration  of  Anes- 
thetics,"  1907,  176. 

^Luke  and  Eoss:    "Anesthesia  in  Dental  Surgery,"    1910,  207. 
^ '  *  American ' '  here  refers  in  fact  to   the  United  States. 


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STATISTICS  857 


CONCLUSIONS 


The  statistical  tables  coincide  remarkably  with  the  principles  advo- 
cated in  these  different  chapters.  Bearing  in  mind  the  pharmacological 
action  and  clinical  history  of  each  anesthetic  as  well  as  the  statistical 
tables,  we  make  the  following  deductions  and  recommendations : 

(1)  Nitrous  oxid  with  oxygen  (with  or  without  ether)  is  the  safest 
inhalation  anesthetic  we  know  of  at  present;  (a)  Kitrous  oxid  should 
not  be  used  alone;  (b)  Nitrous  oxid  should  not  be  used  with  air,  if  oxy- 
gen is  available;  (c)  The  nitrous  oxid-oxy gen-ether  sequence  is  safer 
than  the  nitrous  oxid-ether  sequence;  (d)  The  statistics  bear  out  the 
principles  given  in  Chapter  II  concerning  oxygen  as  a  factor  of  safety. 

(3)  Anesthol  alone  should  not  be  used.  A  study  of  the  tables  will 
show  that  a  steady  decrease  in  the  use  of  this  agent  alone  has  taken  place 
since  1908.  (a)  Anesthol  as  a  preliminary  to  ether  gives  a  safe  se- 
quence, and  has  steadily  increased  in  favor  from  1905  to  the  present 
time;  (b)  The  combination  of  anesthol  and  chloroform  has  steadily  de- 
creased in  use,  showing  that  it  is  unsatisfactory;  (c)  Anesthol,  alone 
or  with  any  other  agent,  should  not  be  given  by  the  closed  method. 

(3)  Ethyl  chlorid  should  not  be  used  as  a  terminal  anesthetic  on 
account  of  its  physiological  action.  It  is  not  safe,  according  to  these 
statistics,  as  a  preliminary  to  chloroform,  nitrous  oxid,  or  anesthol. 

(4)  Chloroform  alone  should  not  be  used  except  in  emergencies,  or  in 
cases  in  which  it  is  specially  indicated.  Its  use  has  steadily  decreased 
from  1905  to  the  present  time,  (a)  The  chloroform-ether  sequence,  as 
shown  by  the  table,  is  relatively  safe,  ranking  higher  than  the  nitrous 
oxid-ether  sequence,  or  ether  alone;  (b)  As  the  majority  of  the  hospitals 
of  the  United  States  use  preliminary  medication,  we  may  conclude  that 
this  factor  of  safety  has  been  employed  when  the  chloroform-ether  se- 
quence was  used;  (c)  The  combination  of  chloroform  and  oxygen,  ac- 
cording to  these  statistics,  is  safer  than  ether  alone. 

(5)  Ether  alone  is  more  generally  used,  according  to  these  statistics, 
than  any  other  agent,  combination,  or  sequence,  comprising  nearly  half 
of  the  488,000  administrations  reported,  (a)  Ether  alone  is  not  as  safe 
as  is  generally  believed;  (b)  Ether  is  materially  safeguarded  by  oxy- 
gen; (c)  Chloroform-ether,  nitrous  oxid-ether,  and  anesthol-ether  are 
relatively  safe  sequences,  ether  being  the  terminal  anesthetic. 

(6)  Sequences  and  combinations,  when  properly  used,  are  safer  than 
any  known  single  anesthetic. 


APPENDIX    I^ 
ETHYL    ETHER 

History  of  Ethyl  Ether. 

Manufacture  of  Ether  :  Ether  from  "Methylated"  Alcohol ;  Ether 
from  Ethylene;  Theories  of  Etherification. 

Purity  of  Ether:  The  Commercial  Purification  of  Ether;  Veri- 
fied Tests  for  Proving  Purity  of  Anesthetic  Ether;  Role  of  Water  in 
Anesthetic  Ether ;  Explanation  of  Changes  Liable  to  Occur  in  Ether  Im- 
properly Stored;  The  Purification  of  Ether  Eemnants  with  the  View  of 
Eemoving  Aldehyd  in  Particular;  Acidity  of  Ether  and  Effect  Thereon 
of  the  Container;  Physiological  Consideration  in  Eeference  to  Small 
Amounts  of  Impurities;  The  Degrees  of  Purity  of  American  Ethyl 
Ethers  Used  for  Anesthesia. 

HISTOEY   OF   ETHYL   ETHER 

Eaymundus  Lullius,"  in  the  thirteenth  century,  and  Basilius  Valen- 
tinus,^  in  the  fifteenth  century,  investigated  the  action  of  sulphuric  acid 
upon  spirit  of  wine,  and  consequently  it  is  possible  that  these  alchemists 
were  acquainted  with  ethyl  ether.*  It  is  to  Valerius  Cordus,  however, 
that  we  owe  our  first  exact  knowledge  of  the  existence  of  the  compound.® 
The  process  of  Cordus  for  the  preparation  of  ethyl  ether  was  published 
by  Conrad  Gessner  in  1552/  and  it  occurs  in  the  later  editions  of  the  first 
legal  pharmacopoeia  of  Germany.'^ 

^  Much  of  this  appendix  is  taken  from  a  paper  by  Baskerville  and  Hamor, 
J.  Ind.  Eng.  Chem.,  3,  Nos.  5  and  6. 

-"Epistola  accurtationis  lapidis  benedicti;  libelli  aliquot  chemici, "  1600,  319. 

^  This  alchemist  refers  to  a  spirit  obtained  in  this  way  which  has  a  ' '  subtle, 
penetrating,  pleasant  taste,  and  an  agreeable  smell."  See  Kopp's  "Geschichte 
der  Chimie,"  1847,  4,  299. 

*  This  is,  in  fact,  generally  assumed,  and  one  would  be  inclined  to  accept  it  as 
correct,  were  the  authenticity  of  their  writings  established. 

°  "Dispensatorium  pharmacorum  omnium,"   1535. 

•^ ' '  Thesauro  Euonymi  de  remediis  secretis, ' '  1552. 

'  This  recipe  is  as  follows :  Equal  parts  of  spirit  of  wine  which  has  been  rec- 
tified three  times  and  sulphuric  acid  are  allowed  to  remain  in  contact  for  two 
months,  and  then  the  mixture  is  distilled  from  a  water-  or  sand-bath;  the  distil- 
late consists  of  two  layers  of  liquid,  of  which  the  upper  one  is  the  oleum  vitrioli 
dulce  verum. 

858 


APPENDIX   I  859 

Ether  is  mentioned  by  Libavius/  Oswald  Cross,^  and  Willis;"  but 
at  the  commencement  of  the  eighteenth  century,  the  details  of  its  prep- 
aration seem  to  have  been  almost  entirely  lost,  even  though  a  mixture  of 
spirit  of  wine  and  ethyl  ether  was  employed  in  medicine  art  this  period. 
This  mixture  was,  however,  introduced  into  commerce  by  Martmeyer, 
an  apothecary  of  Halle,  under  the  name  of  Panacea  vitrioli.  It  was 
recommended  by  Friedrich  Hoffmann,  and  under  the  name  of  Liquor 
anodynus  Hoffmani,  or  Hoffman  sche  Tropfen,  it  became  well  known, 
but  the  preparation  of  this  medicine  was  kept  secret  for  a  considerable 
period,  and  the  positive  presence  of  ethyl  ether — for  that  matter,  its 
existence — was  not  demonstrated  until  it  was  first  prepared  "free  from 
spirit  of  wine." 

In  1730  August  Siegmund  Frobenius  *  described,  in  general  terms, 
the  preparation  of  spiritus  vini  cetliereus,  but  without  publishing  any 
details.^  On  November  18,  1731,  Frobenius  made  experiments  with 
ether  and  phosphorus  before  a  meeting  of  the  Eoyal  Society,*^  and  in  his 
second  contribution  to  the  Eoyal  Society  he  gave  his  method  for  the 
preparation  of  ether  in  more  detail,  but  this  description  was  not  made 
public  until  after  his  death  in  1741,  when  a  detailed  receipt  was  pub- 
lished by  the  secretary.'^ 

The  method  of  Frobenius  was  soon  widely  adopted,  and  several  Ger- 

^"Alchemia,"  1595. 

^ ' '  Basilica  chymiea, ' '  1608. 

^ ' '  Pharmaeeutice  rationalis, ' '   1675. 

"■FMl.  Trans.,  36,  283. 

'^  He  manufactured,  the  ether  in  Hanckewitz  's  laboratory  and  sold  it  at  a  high 
profit.  He  forwarded  some  of  the  new  substance  to  St.  F.  Geoffroy,  and  wrote 
(1730)    as   follows,    after   extolling   the    valuable   properties    of    the    compound: 

" Paratur  ex  sale  violatili  urinoso,  plantarum  phlo^isto,  aceto  valde 

subtili,  per  summam  fermentationem  cunctis  subtilissime  resolutis  et  unitis. " 

"See  Mortimer:     Ihid.,  Abst.,  9,  372. 

''Phil.  Trans.,  Abridg.,  9,  380.  This  may  be  thus  stated  in  abstract:  "Take  4 
lbs.  in  weight  of  the  best  oil  of  vitriol,  and  as  much  in  weight  of  the  best  alcohol, 
or  the  highest  rectified  spirit  of  wine.  .  .  .  First,  pour  the  alcohol  into  a 
chosen  glass  retort,  then  pour  in,  little  by  little,  one  ounce  of  oil  of  vitriol; 
then  shake  the  retort  till  the  two  liquors  are  thoroughly  mixed,  when  the  retort 
will  begin  to  grow  warm;  then  pour  in  more  of  the  spirit  of  vitriol,  and  shake  it 
again."  The  mixture  was  then  placed  on  a  sand  bath,  and  gradualy  heated,  "that 
the  drops  may  fall  so  fast  that  you  may  count  five  or  six  between  each  .  .  . 
continue  this  heat  as  long  as  they  emit  the  scent  of  true  marjoram.  As  soon  as  the 
smell  changes  to  an  acid  .  .  .  take  out  the  fire.  .  .  .  There  remains  be- 
hind an  eleum  vini.  .  .  .  The  second  day,  when  your  glass  is  cold,  infuse  the 
remainder  with  half  as  much  alcohol,  and  distil  again  as  before,  and  you  will  have 
the  same;  the  third  day  again  with  as  much,  and  proceed  as  at  first,  it  gives  it 
again.  Go  on  as  long  as  you  can  obtain  any  (of  the  ethereal  spirit)  till  all  turns 
to  a  carho ;  then  separate  it,  and  alcalize  it  with  spirits  of  salt  armonioB  made 
without  spirits  of  wine,  till  all  effervescence  ceases,  and  distil  once  more  e  Balneo 
Marice ;  so  is  it  ready  for  experiments." 


860  ANESTHESIA 

man  and  French  chemists  studied  the  preparation  of  ethyl  ether.  In 
1757  Antoine  Baume  published  his  "Dissertation  sur  Vcetlier,"  in  the 
first  26  pages  of  which  he  gave  an  historical  discourse  on  cether  vitrio- 
lique.  On  account  of  its  inflammability  ethyl  ether  was  termed  at  this 
time  naphtha^  but  was  also  called  "vitriolic  ether,"  "sulphuric  ether," 
and  "vitriol-naphtha,"  since  it  was  prepared  by  the  action  of  sulphuric 
acid  on  alcohol. 

MANUFACTURE  OF  ETHER 

Valentin  Eose,^  in  the  year  1800,  demonstrated  that  the  name 
"sulphuric  ether"  was  a  misleading  one,  since  this  substance,  when 
pure,  does  not  contain  any  sulphur  or  sulphuric  acid.  Pourcroy^ 
propounded  the  idea  that  ether  is  formed  from  alcohol  by  the  with- 
drawal of  the  elements  of  water.  However,  a  number  of  facts  con- 
tradicted this  view;  for  example,  Frobenius  had  observed  that  the 
residue  in  the  preparation  of  ether  may  again  be  employed  for  a  future 
conversion  of  alcohol  into  ether,  a  fact  which  had  met  with  confirma- 
tion in. the  hands  of  other  chemists,  particularly  Cadet  (1774).^ 

The  discovery  of  the  continuous  process  now  employed  for  the  manu- 
facture of  ether  is  generally  attributed  to  Boullay.  *  Squibb  ^  stated  that 
360  pounds  of  concentrated  sulphuric  acid  sufficed  to  etherify  130  bar- 
rels of  clean  spirit;  the  acid  charge  must  be  then  changed,  as  the  mix- 
ture will  have  become  dark  and  tarry,  and  liable  to  froth  in  the  still.*' 

Ethyl  ether  was  first  manufactured  on  a  large  scale  in  this  country 

^Allg.  J.  Chem.   (Scheerer),  4,  253. 

This  savant  in  conjunction  with  Vauquelin  [Allg.  J.  Chem.  (Scherer),  6,  439] 
made  attempts  to  experimentally  establish  this  view,  the  results  of  which  were 
confirmed  in  1807  by  Saussure  and  in  1815  by  Gay-Lussac,-  both  of  whom  analyzed 
ether.  Then  it  was  thought  that  the  action  of  sulphuric  acid  on  alcohol  could  be 
accounted  for  by  the  fact  that  this  acid  removed  from  the  alcohol  either  the  ele- 
ments of  water  or  water  already  present  in  the  compound. 

^ Mements  d'Mstoire  naturelle  et  de  cMmie,  1789. 

^  Cadet  and  Baume  had  a  discussion  concerning  the  manufacture  of  ether; 
and  the  former  stated  that,  while  Baume  sold  the  compound  at  twelve  livres  per 
ounce,  he  charged  only  forty  sous  for  the  same  quantity.  Quite  pure  ether  was 
prepared  by  Lowitz  in  1796  by  means  of  chlorid  of  lime  ( ?)  (J.  Pharm.  CMm., 
1,  97). 

*  This  process  depends  on  the  fact  that  a  small  quantity  of  sulphuric  acid  is 
sufficient  to  convert  a  large  quantity  of  alcohol  into  ether;  in  fact,  theoretically, 
one  portion  of  sulphuric  acid  will  convert  an  unlimited  quantity  of  alcohol  into 
ether,  but  in  practice  some  of  the  sulphuric  acid  is  reduced,  and  not  only  is  there 
loss  of  acid  and  alcohol,  but,  in  consequence  of  this  reduction,  the  ether  becomes 
contaminated  with  sulphur  dioxid  and  must  be  purified  before  use. 

^  "  Ephemeris, "  2,   590. 

*See  TJ.  S.  Patent  516,  766,  of  1894,  of  Kraft  and  Eoos.  The  production  of 
sulphur  dioxid  in  the  process  may  be  prevented,  it  is  claimed,  by  using  benzene- 
sulphonic  acid  in  the  place  of  sulphuric  acid  in  the  still. 


APPENDIX    I  861 

by  Eosengarten  &  Sons  at  Philadelphia  in  1823,  and  oy  Carter  and 
Scattergood  of  the  same  city  in  1834. 

Ether  from  "Methylated"  Alcohol. — One  of  the  strong  arguments 
in  advocating  the  enactment  of  denatured  alcohol  laws  was  cheaper  ethyl 
alcohol  for  the  manufacture  of  ether.  Ethyl  alcohol  denatured  with 
ten  per  cent  methyl  (wood)  alcohol  was  first  authorized.  "Methylated" 
alcohol  was  then  used  for  the  manufacture  of  ethyl  ether.  Ether  made 
from  methylated  spirit  contains,  according  to  some  authorities,  a  con- 
siderable quantity  of  gaseous  methylic  ether  in  solution,  which  lowers 
the  specific  gravity  and  boiling  point  of  the  preparation.^  Ten  per  cent 
of  methylated  ether  may  be  detected  by  the  mixture  commencing  to  boil 
at  a  lower  temperature  than  ether  prepared  from  rectified  spirit." 

Three  grades  of  ether  prepared  from  methylated  spirit  are  used  in 
Great   Britain.^     Hewitt  *   states   that,   while    it   may   be   regarded    as 

^Abraham:    Chem.   and  Drug.,  41,   520. 

^  Jones  (Pharm  J.  and  Trails.,  16,  663)  obtained  the  following  results  with 
various  British  ethers: 

100  c.c.  tahen.  c.c.  obtained.  Bemarks. 

Eect.    ether,  0.720  0 

Kect.    ether,  0.730  0 

Meth.  ether,  0.717  60  Boiled  freely  at  74°  F. 

Meth.  ether,  0.720  54 

Meth.  ether,  0.730  23 

*  Allen  ["Commercial  Organic  Analysis,"  1908,  1,  181]  has  pointed  out  that, 
owing  to  the  extreme  volatility  of  methylic  ether,  ether  made  from  methylated 
spirit  would  be  practically  pure  ethyl  ether,  were  it  not  for  the  presence  in  it  of 
other  constituents  of  wood  spirit.  This  is  undoubtedly  true  from  a  general  stand- 
point, but  nevertheless  methylic  ether  has  usually  been  considered  to  exist  in  solu- 
tion in  ether  prepared  from  methylated  spirit,  as  determined  by  an  observation 
of  the  commencement  of  boiling.  Williamson  (Ann.,  81,  79 ;  see  also  Norton  and 
Prescott:  Am.  Chem.  J.,  6,  244)  found  that  methyl  ethyl  ether  is  formed  together 
with  methyl '  and  ethyl  ethers  by  the  etherification  of  a  mixture  of  methyl  and 
ethyl  alcohols  by  sulphuric  acid ;  and  since  methyl  ether  boils  at  34°  C,  and 
methyl-ethyl  ether  between  10°  C.  and  13°  C,  the  latter  is  likely  to  occur  'in 
larger  amounts  than  the  former  in  ether  prepared  from  methylated  spirit. 

Ether  of  the  specific  gravity  0.735  has  been  oflficial  in  Great  Britain  for  many 
years,  but  foreign  pharmacopoeias  only  recognize  the  fluid  which  is  official  in  the 
British  Pharmacopoeia  as  "^ther  Purificatus. "  The  latter  is  identical  with  the 
"uEther  pro  narcosi"  of  the  German  and  Swedish  Pharmacopoeias.  In  1893 
Dott  (Pharm.  J.  and  Trans.,  23,  617)  suggested  that  the  specific  gravity  of  the 
official  ether  of  the  British  Pharmacopoeia  should  be  altered  to  "not  exceeding 
0.724."  The  following  ethers  are  used  in  Great  Britain:  (1)  From  Pure  Eecti- 
fied  Spirit:  (a)  aether  (off.).  Sp.  gr.,  0.735.  "Ordinary  medicinal  ether." 
Occasionally  employed  as  an  anesthetic,  but  is  not  so  suitable  for  inhalation  as 
(b)  "ajther  purificatus"  (off).  Sp.  gr.,  0.720-0.722  (British  Pharmacopoeia, 
1898,  26):  (2)  from  Methylated  Spirit:  (c)  "absolute  ether."  Sp.  gr.,  0.717- 
0.719.  Said  to  be  not  adapted  for  general  anesthesia;  (d)  "rectified  ether." 
Sp.  gr.,  0.720.  Reported  as  being  adapted  for  producing  general  anesthesia; 
(e)   "methylated  ether."     Sp.  gr,,  0.730.     Employed  for  common  purposes. 

* ' '  Anaesthetics  and  Their  Administration, ' '  1907,  22. 


862  ANESTHESIA 

hi.r;-hly  probable  that  the  purer  ether  possesses  slight  advantages  over  the 
methylated,  the  latter,  if  carefully  prepared  by  a  recognized  manufac- 
turer, is  certainly  quite  suitable  for  hospital  use.  Eichardson  ^  decided 
in  favor  of  "methylic  ether"  for  rapid  anesthesia. 

Ethers  on  the  American  market — that  is,  those  manufactured  in 
the  United  States  from  rectified  spirit  or  from  denaturant  formulas 
authorized  by  the  Commissioner  of  Internal  Eevenue  ^ — are,  so  far  as 
we  have  been  able  to  ascertain,  free  from  methylic  ether,  methyl-ethyl 
ether;  and  American  ethers  are  not  contaminated  with  these  substances, 
formaldehyd,  or  formic  acid. 

Ether  from  Ethylene. — Fritsche  ^  devised  a  method  for  the  prepara- 
tion of  ether  free  from  alcohol.  In  this  method,  gas  containing  ethylen 
is  treated  with  sulphuric  acid,^  and  the  ethyl-sulphuric  acid  so  obtained 
is  converted  into  ether  and  sulphuric  acid  by  means  of  water.  This 
process  was  operated  on  a  commercial  scale  in  this  country  for  some 
time,^  but  the  industry  was  finally  destroyed  by  the  Denatured  Alcohol 
Act. 

Theories  of  Etherification. — Mitscherlich "  proposed  the  "catalytic 
hypothesis"'  to  account  for  the  action  of  sulphuric  acid  on  alcohol,  and 
Berzelius  adhered  to  the  same  view.  Neither  of  these  chemists  noted, 
however,  that  the  first  action  of  sulphuric  acid  on  alcohol,  in  the  manu- 
facture of  ether,  is  the  production  of  "sulphovinic  acid,"  or  hydrogen 
ethyl  sulphate,  an  observation  which  was  made  by  Hennell.  This  sub- 
ject was  investigated  quite  carefully  by  Liebig.'^  He  concluded  that 
ethyl  sulphuric  ether  was  first  formed,  and  that  this  decomposed  at  a 
temperature  of  -|-  126°  C.  to  -|-  140°  C.  into  ether,  sulphuric  acid,  and 
sulphur  trioxid,  this  latter  combining  instantly  with  the  water  formed 
in  the  reaction;  the  sulphuric  acid  again  formed  ethyl  sulphuric  acid 

"■Med.  Times  and  Gas.,  April  9,  1870. 

-  Alcohol  to  be  used  in  the  manufacture  of  ether  in  the  United  States  may  be 
denatured  with  ether.  See  Eegulations  No.  30,  Supplement  No.  1,  United  States 
Internal  Eevenue;  and  Bulletin  No.  130,  Bureau  of  Chemistry,  1910,  163. 

^  Chem.  Ztg.,  33,  759.    See  also  Pierre :     Ann.  chim.  phys.,  IS,  No.  3,  360,  400. 

*Z.  anal  Chem.  36,  298;   U.  S.  Patent  No.  475,640,  Jan.  19,  1897. 

^  Bull.  92,  U.  S.  Dept.  of  Commerce  and  Labor,  Bureau  of  the  Census,  1909,  96. 
Vaporized  petroleum  was  used  as  a  source  of  ethylene,  and  natural  gas  was  sug- 
gested later,  but  it  was  not  available  in  the  locality  of  the  plant  and  it  was  not 
considered  economical  to  move  the  plant.  Monroe  proposed  erecting  a  by-product 
coke  plant  at  the  locality,  since  this  furnishes  comparatively  large  amounts  of 
ethylene,  but  such  a  step  was  not  taken  owing  to  the  inability  to  secure  encour- 
agement from  the  firm  controlling  the  most  suitable  by-product  coke  oven.  It  is 
likely,  however,  that  a  similar  industry  may  be  revived,  as  natural  gas  might  serve 
as  a  suitable  material  from  which  to  prepare  ether  (cf.  French  Patent,  352,687,  of 
1905,  of  Lance  and  Elworthy). 

"Pogg.  Ann.,  31,  273;   53,  95;    55,   209. 

''Ann.,  23,  39;   SO,   129;    QO,  31. 


APPENDIX    I  863 

with  the  alcohol,  which  was  being  continuany  added,  and  thus  Licjbig 
accounted  for  the  continuous  nature  of  the  reaction.^ 

Williamson  ^  adopted  the  views  of  Laurent  and  (Jerhardt,  and  there- 
fore gave  ethyl  ether  the  molecular  formula  CjH^oO,  whereas  those  using 
the  equivalent  weights  adopted  the  formula  C4H5O.  However,  accord- 
ing to  the  theory  of  types,  alcohol  is  derived  from  water  by  the  replace- 
ment in  it  of  one  atom  of  hydrogen  by  ethyl,  and  hence  ether,  accord- 
ing to  Williamson's  view,  must  be  regarded  as  alcohol,  in  which  the  hy- 
drogen of  hydroxyl  is  replaced  by  ethyl.  By  a  new  synthesis  he  was 
enabled  to  prove  the  correctness  of  this  conception,  not  only  for  etliyl 
ether,  but  for  ethers  in  general.  His  method  was  the  transposition 
taking  place  between  sodium  ethylate  (JSTaOCoHg)  and  ethyl  iodid 
(CoHgl)  ;  and  the  formation  of  ethyl  ether  from  alcohol  and  sulphuric 
acid  Williamson  explained  by  a  continuous  breaking  down  and  reforma- 
tion of  ethyl  sulphuric  acid,  made  possible  by  the  contact  of  alcohol  with 
the  acid  at  +  140°  C. 

Further  confirmation  of  the  views  of  Williamson  was  afterward 
given  by  Berthelot.^  Chancel,*  who  really  preceded  Williamson  in  pub- 
lication, independently  arrived  at  the  same  conclusions,  by  heating  a 
mixture  of  potassium  ethyl  sulphate  and  potassium  ethylate.  The  ob- 
jection that  ethyl  ether,  because  of  its  low  boiling  point,  could  not  con- 
tain the  double  number  of  carbon  atoms  in  its  molecule  Chancel  re- 
moved by  citing  the  boiling  point  of  ethyl  acetic  ester. 

1  The  simultaneous  production  of  water  and  of  anhydrous  sulphuric  acid  was 
accounted  for  by  the  assumption  that  the  latter  only  combined  with  the  water  in 
its  immediate  neighborhood,  while,  in  the  other  parts  of  the  mixture,  the  passage 
of  the  ether  vapor  carried  away  some  water  vapor.  Heinrich  Eose  explained  the 
curious  fact  that  ethyl  sulphuric  acid  should  be  formed  and  decomposed  at  the 
same  time  and  in  the  same  liquid  by  the  suggestion  that  a  diminution  of  tem- 
perature sufficient  to  permit  of  the  formation  of  ethyl  sulphuric  acid  occurred 
at  the  point  where  the  alcohol  flowed  in,  but  that  the  other  portions  of  the  mixture 
were  sufficiently  hot  to  result  in  the  decomposition  of  this  acid.  Mitscherlich 
rendered  this  hypothesis  untenable  (J.  Cliem.  Soc,  3,  24),  by  demonstrating  the 
continuous  formation  of  ether  under  conditions  in  which  no  such  local  diminution 
of  temperature  could  occur.  Graham,  like  Mitscherlich  and  Berzelius,  assumed 
the  existence  of  contact  action,  but  shortly  afterwards  the  investigations  of  Wil- 
liamson placed  the  true  theory  of  the  continuous  etherification  process  on  an  ex- 
perimental basis.  Prior  to  his  work  no  completely  satisfactory  theory  of  the 
formation  of  ether  could  be  established,  due  to  the  lack  of  complete  experi- 
mental evidence  and  owing  to  the  general  use  of  the  equivalent  weights. 

2  Brit.  Assn.  Repts.,  1850,  65;  Phil.  Mag.,  37,  No.  3,  350, 

3  J.  Pharm.,  26,  No.  3,  25. 

4  Compt.   rend.,  6,  369. 


864  ANESTHESIA 


PURITY  OF  ETHER 

The  Commercial  Purification  of  Ether. — The  ether  distillate  re- 
sulting from  the  reaction  between  sulphuric  acid  and  alcohol  is  usually 
treated  with  either  milk  of  lime  or  sodium  hydroxid,  to  remove  the  sul- 
phur dioxid  and  to  absorb  any  "oil  of  wine,"  ^  and  then  further  recti- 
fied.2  The  rectified  ether  is  usually  run  into  tin  cans  provided  with  a 
neck  and  the  cap  is  sealed  by  soldering.^ 

Verified  Tests  for  Proving  Purity  of  Anesthetic  Ether. — Specific 
Gravity  of  Anesthetic  Ether. — The  specific  gravity  of  ether  in- 
tended for  anesthesia  should  not  exceed  0.720  at  15°  C,  providing  an 
ether  containing  minimum  quantities  of  alcohol  and  moisture  is  required ; 
however,  an  ether  which  shows  a  specific  gravity  of  0.7215  (2  per  cent 
absolute  alcohol),  0.7228  (3  per  cent  absolute  alcohol),  or  even  0.724 
(4  per  cent  absolute  alcohol),  providing  the  sole  "impurity"  is  ethyl 
alcohol,  is  acceptable  for  anesthetic  purposes,  according  to  various  phar- 
macopoeias. The  specific  gravity  may  be  best  determined  by  means  of 
a  pyknometer. 

A  convenient  form  of  pyknometer  is  that  devised  by  Squibb  *  and 
also  described  by  Eosengarten,^  the  use  of  which  is  described  on  page 
865. 

Boiling  Point. — The  fractionation  should  show  that  at  least  97  per 
coDit  of  the  sample  distils  over  between  -|-  34°  C.  and  -\-  36°  C.  (at  760 

^  The  term  ' '  heavy  oil  of  wine ' '  is  held  to  signify  the  oil  which  passes  over 
if  the  temperature  is  raised  after  the  preparation  of  ethyl  ether.  Liebig  (Handw. 
d.  Chem.,  3857,  I,  223),  who  found  that  it  passes  over  when  sulphur  dioxid  and 
olefiant  gas  are  given  off,  regarded  ' '  heavy  oil  of  wine "  as  an  ethyl  sulphate  of 
"etherol. "  According  to  Claesson  (J.  praM.  Chem.,  19,  II,  259)  and  SeruUas 
{Ann.  chim.  phys.,  39,  II,  152)  it  consists  of  ethyl  sulphate  mixed  with  olefines. 
The  composition  varies  materially,  and  the  phrase  is  indefinite  and  rather  vague; 
but  it  is  considered  that  the  yellowish  oil  of  a  penetrating  odor  (sp.  gr.,  1.095  to 
1.13)  procurable  in  the  manufacture  of  ethyl  ether  is  a  possible  contaminant  of 
the  latter,  and  the  term  ' '  heavy  oil  of  wine ' '  is  therefore  used  by  way  of  dis- 
tinction. 

^  In  rectification  the  apparatus  devised  by  Mohr  has  had  extensive  use.  This 
consists  essentially  of  a  still  from  which  the  vapor  is  conducted  through  a  vessel 
kept  at  +  35°  C.  by  warm  water.  Here  most  of  the  alcohol  and  water  vapors  are 
condensed  and  the  ether  passes  over  to  be  condensed  in  a  suitable,  well-cooled 
worm. 

^  It  sometimes  happens  that  a  small  amount  of  zinc  chlorid,  used  as  a  flux  in 
soldering  ether  ' '  tins ' '  by  manufacturers,  is  introduced  accidentally  into  the 
ether.  This  constitutes  one  of  the  real  difficulties  in  being  sure  that  an  unopened 
tin  of  ether  is  uncontaminated. 

4  "  Ephemeris, "    1897,   1773. 

5  J.  Ind.  Eng.  Chem.,  1911,  3,  No.   11. 


APPENDIX    I 


865 


mm.),  and  none  of  it  should  come  over  above  -)- 37°  C.  ;^  after  the 
fractionation  to  this  temperature  no  residue  should  remain  in  the  frac- 
tionating vessel. 

Eesidub  (Extractive  MatteK;,  Odok,  and  Acidity). —  (1)   When 


Fig.  283. — A  Calibrated  Pyknometer  of  25  c.  c.  Capacity.  To  determine  its  volume 
the  pyknometer  is  first  weighed  with  water  at  25°  C,  choosing  a  convenient  mark 
on  the  stem,  say  30  or  40,  whichever  may  be  more  convenient,  as  indicated  in  the 
sketch  by  a  line.  The  pyknometer  is  then  filled  with  ether  to  a  little  above  the  mark 
at  which  the  weight  of  water  has  been  determined  and  placed  in  a  1,000  c.  c.  beaker 
containing  water  which  is  carefully  kept  at  25°  C.  and  constantly  stirred  with  a  ther- 
mometer. When  the  volume  of  ether  becomes  constant  in  the  pyknometer,  the 
excess  of  ether  is  drawn  off  by  means  of  a  capillary  pipette  until  the  desired  mark  is 
exactly  reached.  The  pyknometer  is  then  quickly  dried  with  filter  paper  and  weighed. 
A  capillary  pipette  for  this  purpose  is  easily  made  by  drawing  out  an  ordinary  eye- 
dropper. 


25  c.  c.  of  the  sample  are  allowed  to  evaporate  spontaneously  in  a  clean, 
dry  glass  dish,  the  moist  residue  must  possess  no  odor,  and  must  neitiier 

^  Although  the  boiling-point  of  pure  ether  is  +  34.6°  C.  at  760  mm.,  there  are 
no  ethers  of  anesthetic  grade  on  the  market  which  comply  fully  with  this  require- 
ment, owing  to  the  mutually  opposing  influence  of  water  and  alcohol  on  the  boiling 
point,  and  only  ether  distilled  over  sodium  closely  approximates  it.  Since,  there- 
fore, these  influences  render  the  constancy  of  the  boiling  point  as  ordinarily  de- 
termined of  little  or  no  use  as  a  criterion  of  purity,  it  is  suflScient  to  require  that 
ether  shall  commence  to  distil  at  a  temperature  not  under  +  34°  C,  and  that  it 
shall  possess  a  boiling  point  of  +  34°-36°  C. 


866  ANESTHESIA 

redden  nor  bleach  blue  litmus  paper;  this  residue  must  evaporate  com- 
pletely on  a  water  bath,  that  is,  there  should  be  no  fixed  residue. 

(3)  100  c.  c.  of  the  ether  under  examination  are  allowed  to  evapo- 
rate spontaneously  in  a  flask  until  about  15  c.  c,  remain  in  the  vessel. 
This  residue  should  be  free  from  color  and  foreign  odor,  and  should 
comply  in  full  with  the  following  tests : 

(a)  When  5  c.  c.  are  allowed  to  evaporate  at  room  temperature 
after  the  addition  of  2  c.  c.  of  water,  the  residue  should  neither  redden 
nor  bleach  sensitive  light-blue  litmus  paper. 

(b)  When  another  portion  of  5  c.  c.  is  allowed  to  evaporate  on  a 
9  cm.  filter  paper  contained  in  a  porcelain  dish,  no  foreign  odor  (amyl 
compounds,  empyreumata,  pungent  matters,  etc.)  should  be  perceptible 
as  the  last  portions  disappear  from  the  paper,  and  the  latter  should 
be  left  odorless.  The  ether  should  be  added  to  the  paper  in  portions  in 
such  a  manner  as  to  completely  moisten  it  each  time. 

(c)  On  the  addition  of  the  remaining  5  c.  c.  to  5  c.  c.  of  concen- 
trated sulphuric  acid,  kept  cool  during  the  test  and  contained  in  a  glass- 
stoppered  tube  previously  rinsed  with  concentrated  sulphuric  acid,  there 
should  result  no  perceptible  coloration. 

Anesthetic  ether  should  comply  in  full  with  these  tests. 

Acidity. — When  20  c.  c.  of  pure  ether  are  shaken  with  10  c.  c.  of 
pure  water  and  2  drops  of  phenolphthalein,  the  same  depth  of  color 
should  result  on  adding  an  equal  amount  of  IST/lOO  potassium  hydroxid 
solution  as  in  a  test  using  pure  water  alone.^  When  more  than  1  c.  c.  is 
required  the  ether  should  be  rejected  for  anesthetic  purposes. 

AcETALDEHYD. — On  covering  solid  potassium  hydroxid  (two  clean, 
freshly  broken  pieces  about  2  cm.  long  will  answer)  with  40  c.  c.  of  the 
same  in  a  50  c.  c.  glass-stoppered  vessel  and  allowing  this  to  stand  for 
three  hours,  tightly  closed  and  protected  from  the  light,  and  shaking 
occasionally,  the  potassium  hydroxid  should  not  acquire  a  yellowish 
color,  and  no  yellowish  or  brown-colored  substance  should  separate. 
This  is  recommended  as  the  exclusion  test  for  anesthetic  ether.^ 

^When  0.5  c.  c.  of  a  1:  100  alcoholic  solution  of  phenolphthalein  is  added  to 
100  c.  c.  of  water,  0.5  c.  c.  of  N/100  KOH  is  necessary  to  produce  a  distinct  red 
color.  In  this  connection  see  Trommsdorff 's  table  in  Bockman's  "  Chemisch-tech- 
nische  Untersuchungsmethoden  der  Grossindustrie, "  3rd  ed. ;  Cohn's  "Indicators 
and  Test  Papers,"  220;  and  A.  A.  Noyes:  J.  Am.  Chem.  Soc,  32,  815.  It  ap- 
peared from  the  last  mentioned  investigation  that  thymolphthalein  might  be  ad- 
vantageously substituted  for  phenolphthalein  as  the  indicator  in  estimating  the 
acidity  of  ether.  It  was  found,  however,  that,  when  the  former  is  employed,  the 
color  change  is  less  distinct,  and  that  it  is  less  sensitive. 

^  In  order  to  determine  the  value  of  this  test  experimentally,  5  gm.  of  potassium 
hydroxid  were  added  to  the  following  samples  of  ether,  30  c.  c.  of  each  being  used 
in  the  tests: 

(1)  Ether  distilled  over  sodium,  and  containing  mere  traces  of  acetaldehyd; 
(2)    an  ether  containing   0.5   per   cent  of  hydrogen   dioxid  but   otherwise  pure; 


APPENDIX    I  867 

Peroxids. — When  2  c.  c.  of  a  10  per  cent  cadmium-potassium  iodid 
solution  are  well  shaken  with  10  c.  c.  of  the  sample  there  should  result 
no  liberation  of  iodin  within  one  hour.  This  may  be  easily  determined 
by  adding  starch  solution,  although  the  yellow  color  which  results  in  the 
presence  of  the  merest  traces  of  peroxids  is  easy  to  distinguish. 

Role  of  Water  in  Anesthetic  Ether. — The  presence  of  excess  mois- 
ture should  be  guarded  against  in  the  storage  of  ether,  since  ether  in 
contact  with  water  or  moist  air  for  any  length  of  time  gives  rise  to  vari- 
ous impurities  of  an  objectionable  nature.  Thus  anesthetic  ether  may 
develop  impurities  to  be  avoided  quite  as  much  as  if  they  had  been  in- 
troduced in  the  original  materials  or  later  produced  in  the  manufacture 
or  unintentionally  added  in  the  preparation  for  distribution  in  com- 
merce. 

Ether,  when  freshly  distilled  over  sodium,  possesses  a  specific  gravity 
of  0.7178  to  0.719  at  15V4°  C;  but  if  it  is  not,  immediately  after  its 
rectification,  drawn  ofi'  into  vessels,  which  are  at  once  sealed  and  care- 
fully stored,  the  specific  gravity  increases  in  a  short  time.  The  purest 
ether  procurable  on  the  market  is  of   0.718-0.719   specific  gravity  at 

(3)  an  ether  intended  for  analytical  purposes;  this  ether  contained  small  amounts 
of  the  moisture;  (4)  No.  3  after  the  addition  of  3  per  cent  of  absolute  alcohol; 
(5)  No.  3  after  the  addition  of  0.05  per  cent  of  acetaldehyd;  (6)  No.  1  after 
the  addition  of  0.05  per  cent  of  acetaldehyd;  (7)  No.  3  after  the  addition  of 
0.05  per  cent  of  acetaldehyd;  (8)  No.  3  after  the  addition  of  0.10  per  cent  of 
acetaldehyd;    (9)  No.  8  after  the  addition  of  3  per  cent  of  absolute  alcohol. 

After  standing  30  minutes,  Nos.  6,  7,  and  8  possessed  a  brown  color,  and  No. 
9  had  assumed  a  yellow  color.  At  the  end,  of  24  hours  the  following  results  were 
observed : 

(1)  Nil;  (2)  clear,  uncolored,  separate;  potassium  hydroxid  and  ether  color- 
less; (3)  very  small  amount  of  a  brownish  substance;  (4)  brown  solution;  no 
colored  substance  on  the  potassium  hydroxid  as  in  No.  3;  (5)  clear,  uncolored, 
separate;  no  brownish  substance;  (6)  yellow  solution  and  considerable  "aldehyd 
resin";  (7)  as  in  No.  6;  (8)  much  more  considerable  in  amount  than  in  No.  6; 
(9)   red-brown  solution. 

From  these  experiments  it  was  concluded  that  the  yellow  or  brownish  separate 
is  only  caused  by  the  presence  of  acetaldehyd,  and,  in  cases  where  the  ether  is 
tinted  yellow  or  brown,  this  is  often  due  to  the  presence  of  alcohol,  as  well  as 
aldehyd,  the  former  dissolving  the  resin  formed  by  the  latter.  Peroxids  may 
produce  a  turbidity,  but  no  coloration  or  colored  separate. 

There  is  a  source  of  error  in  the  potassium  hydroxid  test,  however.  Just  as 
spirits  stored  in  casks  made  of  wood  containing  tannin  show  a  coloration  with 
potassium  hydroxid,  so  do  samples  of  ether  containing  pieces  of  cork,  the  latter 
being  introduced  from  the  stoppers.  The  coloration  in  this  case  is  probably  due 
to  the  presence  of  quercitannic  acid  and  resinous  matter  extracted  from  the  cork 
through  contact  with  ether.  An  ether  containing  mere  traces  of  acetaldehyd — 
that  is,  aldehyd  not  detectable  by  the  potassium  hydroxid  test — may  thus  be- 
come colored  when  the  test  is  applied,  providing  it  has  remained  in  contact  with 
cork  or  contains  pieces  of  broken  cork,  the  latter  being  by  no  means  unusual  owing 
to  the  form  of  the  neck  of  the  tin  containers  in  use. 


868  ANESTHESIA 

-[-15°  C,  but  this  absorbs  water  on  exposure  to  the  atmosphere  and  rises 
to  0.7.20-0.721  specific  gravity,  when  it  becomes  fairly  constant. 

Explanation  of  Changes  Liable  to  Occur  in  Ether  Improperly 
Stored. — Baskerville^  has  conducted  an  extensive  investigation  on  the 
changes  which  occur  in  ethyl  ether  during  storage,  and  the  experimental 
data  obtained  lead  to  the  conclusion  that  the  oxidation  of  ether  in  the 
presence  of  moisture  is  productive  of  a  series  of  complex  conversions, 
initiated,  however,  by  the  formation  of  hydrogen  dioxid.  The  slow  com- 
bustion of  pure  ether  in  the  presence  of  water,  and  under  such  condi- 
tions as  exist  when  it  is  improperly  stored,  as,  for  example,  varying  tem- 
perature and  in  sunlight,  in  colorless  glass  vessels,  or  in  badly  stoppered 
tin  containers,  would  appear  to  occur  in  the  following  stages : 

(1)  The  formation  of  hydrogen  dioxid  from  water  and  oxygen  of 
the  air.  This  is  particularly  likely  in  cases  where  there  is  direct  expos- 
ure to  light,  and  it  is  more  or  less  activated  by  contact  action. 

(2)  Dissociation  of  hydrogen  dioxid  into  water  and  oxygen,  which 
latter  then  exerts  a  direct  oxidizing  action,  resulting  in  the  formation 
of  the  following:  acetic  peroxid,  acetaldehyd,  and  acetaldehyd  peroxid, 
and  eventually  acetic  acid.  The  formation  of  acetic  peroxid  facilitates 
a  series  of  oxidations,  and,  by  its  hydrolysis  alone,  acetic  and  peracetic 
acids  are  formed.  The  peracetic  acid  then  becomes  converted  into  acetic 
acid  and  hydrogen  dioxid.  Therefore,  it  is  reasonable  to  conclude  that 
a  continuous  cycle  of  changes  occurs  in  ether  during  its  oxidation  and 
that  such  changes  result  in  the  simultaneous  formation  and  occurrence 
of  peroxidized  compounds,  intermediate  (aldehyd)  and  ultimate  (acetic 
acid)  resultants. 

The  Purification  of  Ether  Remnants  with  the  View  of  Removing 
Aldehyd  in  Particular. — Several  methods  have  been  devised  for  the  re- 
moval of  aldehyd  from  ether.  Some  are  secret.  Although  it  is  exceed- 
ingly difficult  to  eliminate  this  impurity  completely,  yet  it  has  been  done 
commercially  and  the  anesthetist  should  insist  upon  his  ethers  being  free 
from  aldehyd. 

Treatment  with  potassium  hydroxid  or  metallic  sodium  serves  to 
remove  not  only  water,  but  also  aldehyd,  and  an  ether  so  treated  con- 
tains mere  traces  of  the  latter  impurity.  Lassar-Cohn  -  has  found  that 
ether  may  be  most  satisfactorily  freed  from  alcohol  and  aldehyd,  how- 
ever, by  boiling  it  with  a  reflux  condenser  for  twenty-four  hours  with 
an  alloy  of  potassium  and  sodium.  The  application  of  any  method 
should  not  be  undertaken  by  any  except  an  experienced  chemist. 

Acidity  of  Ether  and  Effect  Thereon  of  the  Container. — It  has  been 

^  Assisted  by  Hamor,  J.  Ind.  Eng.  CJiem.,  3,  Nos.  5  and  6. 

^  Ann.  284,  226.  This  alloy  is  fluid  at  low  temperatures,  and  is  superior  to 
metallic  sodium  in  that  it  is  not  liable  to  become  encrusted  with  a  protective  layer 
of  hydroxid  and  resin. 


APPENDIX    I  869 

only  within  the  last  twenty-five  years  that  serious  attention  has 
been  given  to  the  detection  of  acidity  in  the  various  anesthetic  ethers. 
None  that  we  have  examined  contained  acids  (sulphurous,  sulphuric, 
acetic)  in  what  may  be  termed  injurious  amounts,  since  the  amount 
present  never  exceeded  0.003  gm.  of  acetic  acid  per  100  c.  c.  of  the  sam- 
ple in  any  instance.  The  degree  of  acidity  is  liable  to  vary  more  or  less 
in  both  directions  in  short  intervals  during  storage  in  glass  vessels,  just 
as  in  the  case  of  the  oxidation  of  ether  itself.  The  variations  in  acidity 
— theoretical,  but  not  in  general  sensible — may  be  due  to  differences  be- 
tween the  rapidity  of  the  oxidation  and  the  saturation  of  the  acids  by 
the  bases  of  the  glass.  In  fact,  the  nature  of  the  ether  container  is  of 
vast  importance  in  the  light  of  the  oxidation  changes  which  are  possible. 
The  extent  of  the  oxidation — or,  for  that  matter,  any  oxidation  at  all — 
is  dependent  upon  the  quality  of  the  glass  used  in  bottles  for  storing 
ether;  and  in  the  case  of  metallic  containers,  in  view  of  some  recent  re- 
searches, it  is  probable  that  all  metals  which  show  anomalous  anodic 
conductivity  are  likely  to  develop  free  hydrogen  dioxid  in  contact  with 
water  and  oxygen.  The  presence  of  such  metals  should,  therefore,  be 
guarded  against. 

Physiological  Consideration  in  Reference  to  Small  Amounts  of 
Impurities. — The  presence  of  small  amounts  of  substances  has  often- 
times been  the  cause  of  a  chemical  reaction  proceeding  in  a  particular 
direction  by  virtue  of  a  so-called  "catalytic"  or  other  kind  of  action.  So 
the  presence  of  even  traces  of  certain  substances,  as  peroxidized  com- 
pounds, aldehyd,  etc.,  may  have  caused  some  reactions  to  be  incorrectly 
explained,  or  to  follow  an  unusual,  or  unaccounted  for,  route.  This  is 
certainly  true  of  the  animal  body,  wherein  the  courses  of  the  myriad 
chemical  reactions  coincident  with  life  processes,  if  they  be  not  really 
such,  are  affected  by  the  presence  of  the  anesthetic  and  undoubtedly 
made  to  take  queer  directions  by  the  simultaneous  presence,  even  in 
small  amounts,  of  an  unsuspected  constituent. 

The  Degrees  of  Purity  of  American  Ethyl  Ethers  Used  for  Anes- 
thesia.— The  main  impurities  contained  in  American  ethers  are,  beside 
alcohol  and  water,  acetaldehyd  and  acids.  As  previously  noted,  the 
presence  of  small  amounts  of  alcohol  is  permissible  or  may  even  appear 
necessary;  but  anesthetic  ethers  should  contain  but  mere  traces  of 
moisture,  and,  as  has  been  indicated,  it  is  desirable  that  they  should  be 
absolutely  water-free.  This  would  undoubtedly  increase  the  cost  of  pro- 
duction; however,  so  long  as  ether  is  supplied  in  small  tins  of  such  a 
size  that  the  contents  are  used  completely  at  an  operation  or  that,  not 
used,  being  little,  may  be  discarded,  and  not  stored,  it  is  only  neces- 
sary that  the  amount  of  moisture  present  be  reduced  to  very  low  per- 
centage. 

The  following  table  will  serve  to  show  the  comparative  purity  of 


870 


ANESTHESIA 


three  samples  of  anesthetic  ether,  purchased  in  the  open  market  by 
Gwathmey  and  submitted  to  Baskerville,  numbered,  and  without  the 
latter  knowina:  the  name  of  the  manufacturer : 


Test 

D 

E 

F 

Sp.  gr.  at  25° 

0.7162 
No  foreign 
odor 
98.50% 

0.5% 

None 

0.0006 

Negative 
None 

Present* 
Present  in 
permissible 

amount 

5.00% 

None 

Present  in 

permissible 

amount 

0.7189 

Id. 
97.00% 
2.00% 
Id. 

0.00015 
Id. 
Id. 
Id. 

Excessive 

6.00% 
Id. 
Id. 

0.7161 

Odor 

Ether  distillate 

Id. 

97 .  50% 

Distillate  above  36° 

1.50% 

"Organic  impurities" 

Id. 

Relative  acidity  in  gm.  acetic  acid  in 
100  c.c 

0.00165 

U.  S.  p.  litmus  test 

Id. 

Residue 

Id. 

Water 

Id. 

Alcohol 

As  in  No.  D 

Relative  total  impurity  (Allen's  ap- 
proximate method) 

5.50% 

Peroxids 

Id. 

Aldehyd 

Excessive  as 

compared 
to  others 

^  In  all  three  samples  the  amount  of  water  present  was  not  excessive  providing 
the  ether  would  be  properly  stored  or  at  once  consumed  completely  by  the  user. 
All  the  samples  were  properly  canned.  The  samples  of  "D"  examined  possessed 
a  relatively  higher  degree  of  uniformity  than  the  samples  "  E  "  and  "  F. " 


The  American  product  is  universally  recognized  as  of  high  grade; 
however,  not  suflScient  attention  has  been  given  to  the  storage  of  ether 
by  the  user,  and  until  the  latter  cooperates  with  the  manufacturer, 
fully  and  intelligently,  the  results  obtained  may  continue  to  be  variable, 
and  rigid  requirements  on  the  part  of  the  producer  are  useless.  How- 
ever, the  purer  the  product  to  begin  with  the  better  results  are  to  be 
expected.  Ether  freed  from  moisture  and  all  but  traces  of  aldehyd  by 
means  of  sodium  or  other  methods  is  not  required  in  this  country  for 
anesthetic  purposes,  and  it  is  generally  considered  satisfactory  if  no 
"after-effects"  are  observed. 


APPENDIX    II 1 
CHLOEOFOEM 

History  of  Chloeoform. 

Preparation  of  Chloroform  :  From  Ethyl  Alcohol ;  From  "Methy- 
lated Spirit";  From  Acetone;  From  Methane;  From  Carbon  Tetra- 
chlorid. 

Varieties  of  Chloroform  of  European  Make:  Chloral  Chloro- 
form; Chloroform  Pictet;  Chloroform  Anschiitz. 

Purification  of  Chloroform. 

The  Decomposition  of  Chloroform:  The  Changes  Which  Chlo- 
roform Undergoes  Upon  Exposure  to  Air. 

Verified  Tests  for  Purity  of  Anesthetic  Chloroform  :  Odor ; 
Eesidue ;  Specific  Gravity ;  Organic  Impurities ;  Acetone ;  Acetaldehyd ; 
Acidity;  The  Decomposition  Products  of  Anesthetic  Chloroform. 

Degrees  of  Purity  of  American  Chloroforms. 

History  of  Chloroform. — Silliman  ^  confused  chloroform  with  ethy- 
len  dichlorid,  stating  that  it  had  been  "long  known  to  chemists  under 
the  name  of  '^oil  of  the  Dutch  chemists'  and  'Dutch  oil/  from  its  discov- 
ery in  1796  by  an  association  of  Dutch  chemists." 

In  1831  Liebig  '^  obtained  chloroform  by  the  action  of  a  water  solu- 
tion of  potassium  hydroxid  on  chloral  and  by  treating  acetone  with 
bleaching  powder.  Almost  at  the  same  time,  however,  Soubeiran  ^  ob- 
tained chloroform  by  the  action  of  bleaching  powder  on  dilute  alcohol, 
terming  the  product  "ether  bichlorid,"  and  he  was  regarded  as  the  dis- 
coverer of  the  compound  until  Liebig  ^  advanced  his  claim  as  having 
been  the  first  to  prepare  it,  although  he  originally  believed  the  substance 
to  be  a  new  chlorid  of  carbon. 

According  to  some  writers,^  Samuel  Guthrie  discovered  chloroform 

^  Much  of  this  appendix  is  taken  from  a  paper  bj  Baskerville  and  Hamor : 
/.  Ind.  Eng.  Chem.,  1912,  4,  Nos.  3,  4,  5,  6,  7. 

2  Am.  J.  Sci.,  5,  No.   2,   240. 

^Pogg.  Ann.,  23,  444;  Ann.,  1,  31,  198. 

*  Ann.  chim.  phys.,  48,  No.  2,  131;  Ann.,  1,  272;  Soubeiran  and  Mialhe:  Ann., 
71,  225. 

5  Ann.,  162,  161.  ^E.  g.,  Wurtz. 

871 


872  ANESTHESIA 

simultaneously  with  Liebig  and  Soubeiran,  and  it  has  also  been  stated  ^ 
that  his  discovery  antedates  that  of  Liebig  by  several  months.  Silliman  ^ 
stated  in  1848  that  "the  production  of  'chloric  ether,'  so-called,  by  the 
action  of  alcohol  with  bleaching  powders,  was  discovered  almost  simul- 
taneously and  without  conference  by  ovir  ingenious  countryman,  Samuel 
Guthrie,  of  Sackett's  Harbor,  New  York,  and  by  M.  E.  Soubeiran  in 
France." 

Liebig  considered  that  he  had  prepared  carbon  trichlorid,  whereas 
he  actually  obtained  chloroform,  and  Guthrie  confused  his  own  product 
with  ethylene  chlorid;  in  both  cases  the  investigations  were  made  in 
1831  and  published  in  the  early  part  of  1832.  Guthrie  prepared  chlo- 
roform without  knowledge  of  the  work  of  Liebig  or  Soubeiran,  and  is 
fully  entitled  to  be  credited  with  its  independent  discovery.^ 

Dumas,*  in  1834,  showed  that  chloroform  contains  hydrogen,  and 
later  he  determined  its  true  formula.'^  Dumas  obtained  chloroform  by 
boiling  tri-chloro-acetic  acid  with  aqueous  alkaline  solutions,  and  it  was 

iPop.  Sci.  Moil.,  12,  738. 

2  Log.  cit. 

3  The  attention  of  Guthrie  appears  to  have  been  directed  to  the  preparation  of 
"chloric  ether"  by  reading  a  passage  in  a  work  by  Silliman  ("Elements  of  Chem- 
istry," 2,  20),  wherein  it  was  stated  that  the  alcoholic  solution  of  "chloric  ether" 
is  of  medicinal  value.  By  the  term  ' '  chloric  ether ' '  Silliman  referred  unmistak- 
ably to  ethylene  chlorid,  which  Guthrie  considered  he  had  prepared  in  ' '  spirituous 
solution"  by  the  action  of  chlorid  of  lime  on  alcohol  of  density  0.844,  whereas 
he  actually  obtained  an  alcoholic  solution  of  chloroform  (Am.  J.  Sci.,  21,  No.  2, 
64).  Silliman,  commenting  on  Guthrie's  original  contribution  {ibid.,  408),  stated 
that  "we  cannot  say  precisely  what  takes  place  during  the  distillation  of  alcohol 
from  chlorid  of  lime.  It  is,  however,  worthy  of  notice,  that,  as  alcohol  is  be- 
lieved to  be  composed  of  olefiant  gas  and  water,  .  .  .  and  as  chloric  ether  has 
been  heretofore  produced  by  the  combination  of  chlorin  and  olefiant  gas,  it  seems 
hardly  to  admit  of  a  doubt,  that  in  distilling  alcohol  from  chlorid  of  lime,  the 
latter  gives  its  chlorin  to  the  olefiant  gas  of  a  part  of  the  former,  and  thus 
produces  chloric  ether,  which  passes  over,  in  solution,  in  another  portion  of  the 
alcohol,  while  the  water  of  that  portion  of  the  alcohol  which  afforded  the  olefiant 
gas,  or  the  water  which  may  be  supposed  to  be  produced  by  a  combination  of  the 
elements,  is  detained  by  the  lime. ' '  The  question  was  raised,  ' '  Can  any  method 
be  devised  by  which  the  alcohol  can  be  detached  from  the  chloric  ether,  and  the 
latter  obtained  concentrated  and  in  quantity?"  Guthrie  later  {ibid.,  22,  105; 
see  also,  Hayes:  Ibid.,  163)  found  that  this  could  be  accomplished  by  distillation 
over  sulphuric  acid,  and  obtained  an  "ether"  possessing  a  density  of  1.486  and 
boiling  at  166°  F.  In  a  communication  to  Silliman,  he  stated  that  "as  chloric 
ether  is  said  to  have  a  specific  gravity  of  only  1.22,  at  45°  F.,  a  boiling  point  at 
152°  F.,  and  to  be  decomposed  by  sulphuric  acid,  evolving  chlorin,  you  may  have 
good  reason  to  doubt  the  purity  of  my  product,  or  the  accuracy  of  my  estimate, 
but  you  can  very  readily  verify  the  first,  and  I  shall  be  found  to  be  very  near 
the  truth  with  the  latter. ' ' 

iAnn.  chim.  phys.,  56,  No.  2,  115;  Ann.,  32,  113. 
6  Ann.  chim.  phys.,  71,  No.  2,  353. 


APPENDIX    II  873 

he  who  gave  the  compound  its  present  name.'^  Eegnault  ^  proved  that 
chloroform  is  the  second  substitution  product  of  methyl  chlorid;  he 
termed  it  "ether  hydrochlorique  de  methylene  bichlorure."  Bcrzelius 
referred  to  chloroform  as  "formylsuperchlorid,"  and  Mitscherlich  as 
"chloratherid." 

Preparation  of  Chloroform. — From  Ethyl  Alcohol. — Soubeiran 
showed  that  chloroform  is  made  by  the  action  of  "bleaching  powder"  on 
dilute  ethyl  alcohol.^  When  ethyl  alcohol  of  various  strengths  is  poured 
upon  "bleaching  powder"  and  distilled,  the  distillate  affords  an  oil 
which  may  be  separated  by  fractionation.*  A  small  amount  of  ethyl 
chlorid  is  also  formed.'' 

According  to  the  process  of  Schering/  chloroform  is  produced  when 
halogen  salts  of  the  alkalies  or  alkaline  earths  are  electrolyzed  in  the 
presence  of  alcohol,  acetone,  or  aldehyd  in  a  warm  aqueous  solution. '^ 

Although  ethyl  alcohol  was  formerly  used  for  the  production  of  chlo- 
roform, it  is  now  largely,  or  almost  entirely,  replaced  by  acetone.  Kecently 
carbon  tetrachlorid  has  become  an  important  source  of  chloroform. 

From  "Methylated  Spirit." — Pure  methyl  alcohol  does  not  yield 
chloroform  when  treated  with  bleaching  powder,  although  it  is  formed 
from  commercial  methyl  alcohol.^  "Methylated  chloroform,"  at  one 
time  extensively  used  in  England,  is  chloroform  prepared  from  wood 

^  Ibi(T.,  56,  No.  2,  120.  To  quote  Dumas:  "La  formule  .  .  .  correspond  a 
une  chlorure  d'hydrogene  carbone,  qui  est  1 'equivalent  de  I'acide  formique  an- 
hydre     .     .     .     C'est  ce  qui  m 'engage  a  la  designer  sous  le  nom  de  chlorof orme. " 

^Ihid.,  71,   No.  2,  ^17 ;  Ann.,  33,  328;  J.  pralct.  Chem.,  19,  210. 

'  See  also,  Bechamp :  Ann.  cJiim.  phys.,  22,  No.  5,  347. 

For  papers  on  the  manufacture  of  chloroform  from  alcohol  and  ' '  chlorinated 
lime,"  see  Am.  J.  Pharm.,  1862,  25,  42;  1868,  289. 

In  Chem.  Ztg.,  10,  338,  is  described  the  process  in  use  in  Germany  in  1886; 
see  also  Frerichs:  Am.  Inst.  Chem.  Eng.,  1911;  J.  Ind.  Eng.  Chem.,  4,  No.  5. 

On  the  preparation  of  chloroform  from  alcohol,  see,  in  addition,  Goldberg: 
/.  pralct.  Chem.,  132,  111;  Soubeiran:  Compt.  rend.,  25,  799;  Meurer:  Chem. 
Centr.,  1848,  154;  Carl:  Ibid.,  1848,  236;  Larocque  and  Hurault:  N.  J.  Pharm., 
13,  97;  Siemerling:  N.  Br.  Arch.,  53,  23;  Kessler:  N.  J.  Pharm.,  13,  162;  Eam- 
dohr:  N.  Br.  Arch.,  83,  280;  and  Hirsch:  IMd.,  107,  137.  The  alcohol  used  should 
not  contain  fusel  oil  [Regnault  and  Hardy:  J.  pharm.  chim.,  (4),  30,  405]  or 
higher  alcohols. 

*Dott  (/.  Soc.  Chem.  Ind.,  27,  6,  271)  gives  the  reaction:  SC^HsOH  + 
8Ca(OCl)2  =  2CHCI3  -f  3CaC03  +  CO^  +  8H,0  -f  SCaCl^. 

°  Finnemore  and  Wade:    J.  Chem.  Soc.,  85,  938. 

'German  Patent  29771,  1884;  Ber.  17,  624;  also  Dony-Hennault :  Z.  EleJc- 
trochem.,  7,  57. 

'Kempf  {Eng.  Pat.  8148,  1884)  invented  a  process  for  the  manufacture  of 
chloroform  by  electrolyzing  suitable  halogen  compounds  of  the  alkalies  and  alka- 
line earths  in  alcoholic  solution  with  constant  heating;  and  Trechinski  (J.  'Buss. 
Phys.-Chem.  Soc,  38,  734;  Pharm.  Ztg.,  51,  523)  prepared  chloroform  by  the 
electrolysis  of  an  aqueous  alcoholic  solution  of  calcium  chlorid. 

^Belohoubek:  Ann.,  165,  349. 


874  ANESTHESIA 

spirit  ("methylated  spirit").^  It  is  incorrect  to  suppose  that  "methy- 
lated chloroform"  has  received  an  actual  addition  of  methyl  alcohol,  but 
such  chloroform  is  liable  to  be  much  less  pure  than  that  obtained  solely 
from  ethyl  alcohol.  According  to  Allen,^  chloroform  prepared  from 
"methylated  spirit"  is  more  difficult  to  purify  than  that  made  from 
ethyl  alcohol  alone;  but  a  product  has  been  manufactured  in  England 
from  the  former  source  which  appears  to  be  equal  in  all  respects  to  that 
prepared  from  straight  ethyl  alcohol.^ 

From  Acetone. — The  preparation  of  chloroform  from  acetone  was 
referred  to  by  Liebig  in  1832.  Bottger,  in  1848,  showed  how  to  pre- 
pare chloroform  from  acetates  and  from  acetone.  The  process  was  not 
quickly  followed  probably,  as  indicated  by  Squibb,*  on  account  of  the 
erroneous  statements  of  Siemerling  (1848)  and  Wackenroder,  adopted 
by  such  authorities  as  Gmelin  and  Watts. ^  Orndorff  and  Jessel  **  found 
that  the  products  formed  by  the  action  of  bleaching  powder  on  acetone 
are  chloroform,  calcium  hydroxid,  calcium  chlorid,  and  calcium  acetate. 
Numerous  patents  '^  have  been  granted. 

Chloroform  is  now  made  by  electrolysis  of  sodium  (or  other)  chlo- 
rid in  acetone.®    A  strong  prejudice  in  the  pharmaceutical  trade  against 

^ ' '  Methylated  spirit "  is  a  mixture  of  rectified  spirit  with  10  per  cent  of  wood 
alcohol  (methyl  alcohol)  ;  it  has  been  used  in  the  manufacture  of  chloroform 
owing  to  its  being  obtained  duty  free    (Thorpe). 

^"Commercial  Organic  Analysis,"  3908,  1,  235.  "Methylated  chloroform"  is 
not  on  the  American  market. 

^  Allen  is  also  authority  for  the  statement  that  imperfectly  purified  ' '  methy- 
lated chloroform ' '  is  specifically  lighter  than  the  pure  substance,  'has  an  em- 
pyreumatic  odor,  and  produces  disagreeable  sensations  when  inhaled.  In  some 
cases,  we  are  told,  such  chloroform  appears  to  be  actually  poisonous,  and  pro- 
duces general  and  rapid  prostration.  Such  chloroform  contains  several  units  per 
cent  of  a  chlorinated  oil,  lighter  than  water  and  boiling  at  a  much  higher  tem- 
perature than  chloroform.  A  similar  but  different  oil  (heavier  than  water)  has 
been  detected  in  much  smaller  quantity  in  chloroform  prepared  from  alcohol  con- 
taining no  methyl  compounds;  these  oils  may  be  totally  eliminated  by  purification 
of  the  crude  chloroform. 

V.  Am.  Chem.  Soc,  1896,  231. 

^A  Dictionary  of  Chemistry,  1,  918;  also  Siemerling:  Arch.  Pharm.,  S3,  No. 
2,  23. 

^  Am.  Chem.  J.,  10,  366.  Dott  (Pharm.  J.,  81,  54)  found  that  there  are  also 
considerable  amounts  of  calcium  carbonate  and  chlorate  in  the  residual  liquor  ob- 
tained in  preparing  chloroform  from  acetone. 

"Michaelis,  U.  S.,  322,194  (1885);  Michaelis  and  Meyer,  England,  8523, 
(1880)  and  Germany  36,514  (1886)  ;  Eumpf,  U.  S.,  383,992  (1888)  ;  Porsch,  U.  S., 
573,482   (1896);    Chute,  U.   S.,  893,784   (1908). 

"■Bev.  Prod.  CMm.,  3,  309;  Klar.  Chem.  Ind.,  19,  159.  Teeple  (J.  Am.  Chem. 
Soc,  26,  536)  found  that  the  conditions  necessary  for  the  successful  preparation 
of  chloroform  by  the  electrolysis  of  a  chlorid  in  the  presence  of  acetone  are: 
A  temperature  below  -(-25°  C,  absence  of  alkali,  a  high  current  density  at  the 
cathode  and  a  low  one  at  the  anode. 


APPENDIX    II  875 

chloroform  from  this  source  doubtless  had  somethiu"^  to  do  with  causing 
manufacturers  to  be  reluctant  about  divulging  any  information  concern- 
ing the  process. 

Feom  Methane  (ISTatural  Gas). — Pennsylvania  natural  gas  con- 
tains 50-95  per  cent  of  methane/  and,  bearing  i]i  mind  tjie  dcmionstra- 
tion  of  Regnault  -  that  chloroform  is  formed  by  the  action  of  cihlorin 
on  methane  in  daylight  and  quickly  in  sunlight,  several  investigators 
have  sought  to  effect  a  chlorination  in  order  to  obtain  substitution 
products.  So  far,  although  numerous  patents  have  been  secured,  no 
process  for  making  chloroform  from  methane  has  been  operated  com- 
mercially with  success.^ 

From  Caebon  Tetrachlorid. — Geuther  found  that  chloro- 
form results  from  the  action  of  nascent  hydrogen  (from  zinc 
and  sulphuric  acid)  upon  carbon  tetrachlorid.*  It  was  not  until 
successful  commercial  processes  for  the  production  of  carbon  tetra- 
chlorid had  been  developed,  however,^  that  it  was  ascertained  that 
chloroform  might  be  advantageously  prepared  from  carbon  tetra- 
chlorid. 

In  1902  A.  W.  Smith  devised  a  process  of  making  chloroform  from 
carbon  tetrachlorid,  which  process  consists  of  the  following  stej)s :  The 
action  of  heated  sulphur  upon  heated  carbon,  so  as  to  produce  carbon 
disulphid ;  the  action  of  chlorin  upon  sulphur,  so  as  to  produce  sulphur 
chlorid  or  dichlorid;  the  action  of  sulphur  chlorid  or  dichlorid  upon 
carbon  disulphid,  so  as  to  produce  carbon  tetrachlorid;  and,  finally,  the 
reduction  of  carbon  tetrachlorid,  so  as  to  produce  chloroform.  It  has 
been  stated  that  "technically  piire"  chloroform  produced  from  disul- 
phid-tetrachlorid  may  be  recognized  by  its  small  content  of  carbon  di- 
sulphid and  carbon  tetrachlorid,  and  that  such  a  grade  also  possesses  a 
higher  refractive  index  than  other  varieties.  "Anesthetic  chloroform" 
made  from  carbon  tetrachlorid  conforms  in  full  with  the  required 
pharmacopeial  standards.     From  chemical  evidences,  any  prejudice  at- 

^  Pennsylvania  natural  gas  contains  from  50  to  99  per  cent  total  paraffins ; 
Ohio  gas,  90  to  93  per  cent;   and  West  Virginia   Jas,  80  to  87  per  cent. 

^  Ann.  chim.  -phys.,  71,  No.  2,  380. 

^  These  processes  are  summarized  in  the  paper  by  Baskerville  and  Hamor, 
loc.  cit. 

"■Ann.,  107,  212. 

°  As  early  as  1834  it  was  learned  that  carbon  disulphid  may  be  converted 
into  carbon  tetrachlorid  by  chlorination  (Kolbe:  Ann.  45,  41;  54,  146;  see,  also, 
Hofmann:  md.,  115,  264;  Klasow:  Ber.,  20,  2376;  Mouneyrat:  Bull.  soc.  chim., 
19,  No.  3,  262;  and  Serra:  Gaz.  chim.  ital,  29,  353).  Muller  and  Dubois  {'Eng. 
Fatent  19,628,  1893)  devised  a  process  for  the  production  of  carbon  tetrachlorid 
by  the  addition  of  a  finely  divided  iron  to  a  mixture  of  carbon  disulphid  and 
sulphur  chlorid;  cf.  Eng.  Patent  13,733  of  1901,  of  Urbain,  wherein  practically 
the  same  process  is  claimed;  and  V.  S.  Patent  753,325,  dated  March  1,  1904,  cf 
A.  W.  Smith. 


876  ANESTHESIA 

tached  to  such  chloroform  is  without  foundation,  and  there  should  be  no 
hesitancy  in  disclosing  the  source. 

Varieties  of  Chloroform  of  European  Make. — Considerable  quanti- 
ties of  chloroform  are  produced  in  Germany  by  special  purification 
processes  for  domestic  and  foreign  consumption.^  Some  of  these  are  on 
the  American  market. 

In  addition  to  anesthetic  chloroform  prepared  by  the  action  of 
bleaching  powder  on  alcohol  and  acetone  (Chloroform  Gehe,  Riedel, 
Merck,  Kahlhaum,  de  Haen,  Konig  and  Cotta),  "chloroform  e  chlo- 
ral/' "chloroform  Pictet/'  and  "chloroform  Anschiitz"  are  found  on  the 
German  market. 

Chloeal-Chloeofoem. — Liebig  found  that  chloroform  may  be  pre- 
pared by  distilling  chloral  with  excess  of  aqueous  potassium  hydroxid, 
sodium  hydroxid,  or  baryta,  or  with  milk  of  lime,  repeatedly  agitating 
the  oily  distillate  with  water,  separating  from  the  water  as  completely 
as  possible  by  decantation,  and  then  distilling  with  6  or  8  times  its  vol- 
ume of  strong  sulphuric  acid  in  a  perfectly  dry  apparatus.  In  1870 
chloral-chloroform  was  sold  under  the  name  "English  Chloroform"  in 
Germany,  and  Hager,  after  an  examination,  expressed  the  opinion  that 
chloroform  from  chloral  was  the  purest  then  obtainable.^ 

The  invention  of  Liebreich  ^  for  preparations  for  the  production  of 
chloroform  relates  broadly  to  a  product  consisting  of  a  dry  mixture  of 
chloral  hydrate  and  alkali,  which  may  be  compressed  into  any  con- 
venient shape;  on  treatment  with  water  chloroform  is  produced.  The 
product  of  this  process  has  been  known  as  "chloroform  Liebreich,"  and 
"chloroform  Sobering,"  now  on  the  American  market,  is  prepared  from 
Liebreich's  crystallized  chloral  hydrate. 

Langgaard  *  examined  the  eight  principal  brands  of  chloroform  ob- 
tainable in  Germany,  and  found  that  chloral-chloroform  was  the  purest. 

^In  1910,  for  example,  161,900  kg.  of  chloroform  and  chloral  were  exported, 
19,000  kg.  of  which  went  to  the  United  States;  the  average  price  was  from  170  to 
180  marks  per  100  kg. 

'Year-Boole  of  Pharm.,  1870,  119.  Hager  found  that  "English  chloroform" 
was  really  chloral-chloroform  containing  0.75  to  0.80  per  cent  of  alcohol.  The 
addition  of  pure  sulphuric  acid  to  this  chloral-chloroform  caused  no  coloration, 
while  it  was  found  to  color  slightly  the  ordinary  grade  of  chloroform  then  in  use. 
Evaporation  of  some  of  the  substance  on  a  watch-glass  in  the  air  was  found  to 
afford  another  means  of  testing  the  substance.  When  all  but  a  few  drops  had 
disappeared,  the  ordinary  chloroform  residue  was  found  to  possess  a  disagreeable 
odor,  while  the  other  retained  its  pleasant  odor.  Versmann  (Pharm.  J.,  2,  No.  3, 
63)   also  found  that  the  residue  of  chloral  chloroform  possessed  no  foreign  odor.. 

According  to  a  later  writer,  however  (Arends:  Pharm.  Ztg.,  1891,  263),  Ger- 
man chloroform  is  generally  superior  to  that  manufactured  in  England.  The 
British  Pharmacopoeia  is  considerably  less  stringent  than  that  of  Germany. 

^Eng.  Patent  15,930,  1904. 

*Therap.  Monatsch.,  May,  1902. 


APPENDIX    II  877 

As  a  general  rule,  however,  all  of  the  German  chloroforms  of  anesthetic 
grade  are  of  good  quality/  and  the  grade  at  present  pres(;ribed  by  the 
Arzneihuch  is,  at  least  in  most  cases,  equal  to  chloroform  prepared 
from  chloral.  It  has  also  been  claimed  that  chloral  chloroform  does  not 
undergo  decomposition,  but  this  has  been  shown  to  be  incorrect;  ^  in  fact, 
like  all  the  other  pure  preparations,  "chloroform  e  chloral"  decomposes 
if  not  preserved  by  the  addition  of  a  little  alcohol.^ 

Chloroform  Pictet. — This  preparation  is  obtained  by  crystalliza- 
tion at  a  low  temperature,  followed  by  fractional  distillation  (referred 
to  again  later).  Schacht  has  shown  that,  although  the  Pictet  chloro- 
form is  a  good  preparation,  that  obtained  from  the  purest  crystallized 
chloral  hydrate  is  quite  equal  to  it,  and,  like  the  latter,  it  requires 
a  preservative  to  keep. 

Chloroform  AnschiItz. — More  recently  a  special  preparation  un- 
der the  name  "Anschiitz  salicylid  chloroform"  or  "Salicylchloroform"  has 
been  placed  on  the  German  market;  it  is  obtained  from  a  crystalline 
compound  of  salicylid,  and  was  first  prepared  by  Anschiitz.* 

Purification  of  Chloroform. — The  crude  chloroform  prepared  by 
the  action  of  bleaching  powder  on  alcohol;  by  the  action  of  bleaching 
powder  on  acetone  f  or  by  the  electrolysis  of  solutions  of  chlorids  of  the 
alkalies  or  alkaline  earths  in  alcohol  or  acetone,*'  is  not  of  so  high  a  de- 
gree of  purity  as  that  obtained  by  the  action  of  alkalies  on  previously 
purified  chloral,  and  requires  more  careful  purification  before  it  is  suit- 
able for  anesthetic  purposes.  The  extent  of  the  purification  necessary 
is  dependent  upon  the  purity  of  the  materials  used  as  well  as  upon  the 
process  employed. 

^  The  results  obtained  by  Baskerville  and  Hamor  in  the  course  of  an  examina- 
tion of  the  principal  German  products  may  be  found  in  their  paper,  loc.  cit. 

'See  Am.  J.  Pharm.,  42,  409. 

=  See  Schacht:   J.  Soc.  Chem.  Ind.,  1893,  543. 

*J.  Soc.  Chem.  Ind.,  1893,  782.  According  to  the  patented  process  of  An- 
schiitz, chemically  pure  chloroform  is  produced  by  decomposing  by  heat  double 
compounds  of  chloroform  and  lactid-like  condensation  products,  derived  from 
orthophenol  carbonic  acids,  as  salicylid,  and  then  condensing  the  pure  chloro- 
form; salicylid-chloroform  is  prepared  by  boiling  salicylid  in  chloroform  (U.  S. 
Patent  535,270,  1895),  and  in  this  compound  chloroform  plays  the  same  role  as 
the  water  of  crystallization  in  many  crystalline  salts,  being  obtained  in  a  pure 
state  by  simple  distillation  therefrom  (Anschiitz:  Ann.,  273,  94;  Arends:  Chem. 
Ind.,  16,  78).  Salicylid-chloroform  is  said  to  be  extensively  used  by  anesthetists 
in  Eussia,  it  conforming  to  the  pharmacopoeia  of  that  country,  and  is  especially 
recommended  for  anesthesia  by  many. 

The  comparative  prices  of  chloroform  prepared  from  acetone  by  means  of 
bleaching  powder,  chloroform  from  chloral  by  potassium  hydroxid,  "chloroform 
Pictet, ' '  and  ' '  chloroform  Anschiitz, ' '  are,  respectively,  taking  the  first  as  a  basis, 
1^  3,  6,  and  9. 

"See  Pharm.  J.,  M,  No.  3,  84. 

»jSee  J.  Soc.  Chem.  Ind.,  1885,  243. 


878  ANESTHESIA 

The  earliest  methods  for  the  purification  of  crude  chloroform  con- 
sisted in  washing  the  distillate  with  water  to  remove  alcohol/  and  then 
drying  over  calcium  chlorid,  or  sometimes  rectifying  without  having 
previously  dried  the  product.  In  1848  the  crude  chloroform  was  puri- 
fied by  shaking  with  potassium  hydroxid,  drying  over  calcium  chlorid, 
and  then  rectifying ;  this  method  served  to  remove  chlorin  ^  and  acids, 
but  it  only  partially  eliminated  alcohol  and  other  probable  contam- 
inants. 

Gregory^  purified  chloroform  by  agitating  it  and  leaving  it  in  con- 
tact with  sulphuric  acid  until  the  latter  was  no  longer  colored  by  it; 
then  he  removed  the  chloroform  and  placed  it  in  contact  with  a  small 
quantity  of  manganese  dioxid  to  free  it  from  "sulphurous  acid."  About 
1860  the  German  custom  was  to  rectify  overconcentrated  sulphuric 
acid.*  At  the  present  time  treatment  with  sulphuric  acid  is  generally 
resorted  to,  and  forms  the  most  important  stage  of  the  purification  of 
crude  chloroform  prepared  from  alcohol  or  acetone.  Pure  concentrated 
sulphuric  acid  has  no  action  on  chloroform  itself  unless  the  operation 
is  unduly  prolonged,^  but  it  decomposes  some  of  the  impurities  which 
are   commonly  present,   and  removes   others.      In   the   next  place,   the 

^  When  made  from  alcohol,  crude  chloroform  contains  considerable  quantities 
of  alcohol  in  solution,  from  which  it  may  be  separated  by  repeatedly  washing 
with  water.  In  order  to  wash  a  yield  of  160  to  175  kg.  of  crude  chloroform,  about 
800  liters  of  water  are  necessary  to  obtain  anesthetic  chloroform,  although  this 
washing  forms  only  one  stage  of  the  purifying  process. 

^  Kessler  [J.  Pharm.  Chim.,  13,  (3),  162]  found  that  chloroform  may  be  freed 
from  chlorin  by  agitation  with  potassium  hydroxid,  and  suggested  that  it  be 
further  purified  by  drying  over  calcium  chlorid  and  followed  by  rectification. 

^  Proc.  Eoy.  Soc.  Ednh.,  1850,  391.  According  to  Abraham  {Pharm.  J.,  10, 
24)  chloroform,  when  thus  purified,  quickly  decomposes,  and  is  afterwards  found 
to  contain  hydrochloric  acid  and  free  chlorin. 

*  The  United  States  Pharmacopoeia  of  1850  gave  a  process  for  preparing 
chloroform;  this  was  transferred  in  1860  to  the  Materia  Medica  Catalogue. 
' '  Chloroform  venale, ' '  or  commercial  chloroform,  was  introduced  and  also  a 
formula  for  purifying  chloroform;  this  was  dropped  in  the  Pharmacopoeia  of  1890. 

°  Christison  {Pharm.  J.,  10,  253)  found  that  chloroform  keeps  well  after  being 
once  treated  with  sulphuric  acid;  but  that  the  continued  action  of  that  liquid, 
especially  if  it  is  contaminated  with  nitrous  acid,  exerts  a  decomposing  action 
on  it.  Tilden  {ibid.,  1,  No.  3,  623)  stated  that  the  sulphuric  acid  used  to  purify 
chloroform  must  be  free  from  all  traces  of  nitrogen  oxids;  and  it  was  his  opinion 
that  the  decomposition  of  chloroform  may  be  attributed  to  contamination  of  this 
kind.  Eedwood  {ibid.,  12,  No.  3,  734)  was  inclined  to  ascribe  the  improved 
quality  of  the  British  chloroform  of  1882  to  the  care  used  in  its  manufacture, 
particularly  to  the  attention  paid  to  the  purity  of  the  sulphuric  acid  used  in  the 
purification.  Clark,  however,  maintained  that  the  presence  cf  nitrous  or  nitric 
acid  in  the  sulphuric  acid  was  not  the  cause  of  the  instability  of  chloroform. 
Both  Clark  and  Dott  considered  ' '  that  the  decomposition  of  chloroform  is  not 
probably  due  to  the  presence  of  nitric  acid  in  the  sulphuric  acid"  {vide  Preston, 
ibid.,  12,  No.  3,  981). 


APPENDIX   II  879 

product  is  brought  in  contact  with  sodium  carbonate/  or  it  is  washed 
with  lime  water  and  then  dried  over  calcium  chlorid.^  In  any  case,  it 
should  be  finally  distilled  at  a  temperature  not  above  -(-  64°  C.^ 

Various  other  methods  have  been  proposed  for  the  purification  of 
chloroform,  especially  when  it  has  become  contaminated  with  decom- 
position products.  We  have,  for  example,  the  method  of  Gibbs,  wherein 
lead  dioxid  is  employed ;  *  that  of  Mentin,  according  to  which  the  chlo- 
roform is  distilled  over  2  per  cent  of  paraffin  at  61°;^  and  the  recom- 
mendation of  Shuttleworth  "^  that  agitation  with  a  dilute  solution  of 
sodium  thiosulphate  be  employed^ 

*  Shuttleworth  (Am.  Chemist,  4,  339)  observed  that  in  samples  of  chloroform 
imperfectly  rectified,  as  that  of  the  ordinary  German  manufacture  of  1873,  the 
impurities  produced  by  the  agencies  of  time,  light,  moisture,  and  atmospheric  ex- 
posure are,  after  a  lapse  of  some  months,  easily  recognizable.  Traces  of  sulphuric 
acid  were  found  to  quickly  induce  this  change;  and  when  that  chemical  has  been 
employed  as  the  purifying  agent,  and  has  not  been  completely  removed  by  re- 
peated washings  and  rectifications,  the  product  will  very  soon  give  sharp  indica- 
tions of  decomposition.  The  method  of  purification  adopted  by  the  British  Phar- 
macopoeia of  that  time  consisted  in  mixing  the  chloroform  after  treatment  with 
acid,  with  lime  and  calcium  chlorid,  and  then  rectifying  at  once.  Shuttleworth 
considered  that  the  keeping  qualities  of  the  product  would  be  much  improved  by 
agitating  the  chloroform,  followed  by  washing  with  water.  Werner  (Arch. 
Pharm.,  25,  No.  3,  1113)  stated  that  his  method  of  purification  afforded  a  product 
found  to  be  perfectly  satisfactory  for  medicinal  use  during  10  years'  experience. 
This  method  (ibid.,  1^,  No.  3,  481)  consisted  in  shaking  the  chloroform  with  one- 
fourth  its  volume  of  distilled  water,  removing  the  latter  the  next  day,  then  agitat- 
ing the  chloroform  with  fused  sodium  carbonate,  and  allowing  the  mixture  to  stand 
for  24  hours.  After  removing  the  sodium  carbonate  the  residual  product  was  dis- 
tilled on  a  water  bath,  the  distillate  coming  over  below  -f-  64°  C.  being  used. 

^Thayer  (/.  Physical  Chem.  3,  36)  found  that  traces  of  alcohol  remained  in 
chloroform  even  after  the  latter  had  been  allowed  to  stand  over  calcium  chlorid 
for  a  long  time.  He  purified  chloroform  by  washing  it  repeatedly  with  water, 
then  keeping  it  in  contact  with  calcium  chlorid  for  two  days,  and  finally  decant- 
ing and  distilling  over  fresh  calcivim  chlorid. 

*See  Werner,  loc.  cit.;  Thorpe,  loc.  c%t.;  Eemys,  Archiv  Pharm.,  5,  III,  31; 
and  Michaelis  and  Mayer,  Polyt.  J.,  261,  49G. 

*  Trans.  N.  Y.  Acad.  Med.,  1,  146.  Gibbs  suggested,  in  1850,  that  chloroform 
possessing  an  acid  reaction  and  probably  containing  chlorinated  oils  be  treated 
with  lead  dioxid.  Metcalfe  (ibid.)  found  that  such  treatment  served  to  remove 
any  disagreeable  odor  characteristic  of  such  chloroform. 

^  Ann.   chim.  fran.,  10,  No.   4,  32. 

'^  Am.  Chemist,  4,  339.  Shuttleworth  recommended  that  chloroform  which  has 
been  injured  by  time  exposure  be  restored  by  agitating  well  with  a  dilute  solution 
of  sodium  thiosulphate,  separating  from  the  supernatant  liquid  and  washing  with 
water,  then  separating  and  passing  the  chloroform  through  filter  paper  to  free  it 
from  traces  of  moisture. 

"  Although  this  method  yielded  an  improved  chloroform,  Shuttleworth  consid- 
ered that,  when  a  pure  preparation  is  desired,  the  impurities  not  removable  by  thio- 
sulphate, those  of  a  more  stable  character  and  possessing  a  higher  boiling  point 
than  chloroform,  be  removed  by  distillation  or  by  treatment  with  sulphuric  acid. 


880  ANESTHESIA 

Yvon  ^  stated  that  he  was  enabled  to  obtain  an  absolutely  pure  chlo- 
roform by  treatment  with  an  alkaline  potassium  permanganate  solution ; 
this  procedure  has  not  come  into  use.  Useless  also,  providing  the  chlo- 
roform has  been  brought  to  the  proper  state  of  purity  prior  to  frac- 
tionation, is  the  French  practice  of  distilling  over  poppy  oil.^ 

In  the  process  of  Pictet  ^  commercial  chloroform  is  cooled  to  —  80° 
C,  and  the  solid  bodies  are  removed  by  filtration;  it  is  then  cooled  to 
—  82°  C,  and  the  non-crystallizable  portions,  which  contain  impurities, 
are  removed ;  the  solid  chloroform  is  melted  and  then  distilled  at  a  very 
low  temperature,  under  reduced  pressure,  and  the  middle  80  per  cent  of 
the  product  is  taken  as  "chemically  pure"  chloroform. 

On  its  introduction  it  was  announced  that  "chloroform  Pictet"  had 
been  experimentally  proved  to  possess  a  capability  of  resisting  the  influ- 
ence of  sunlight  for  four  days.  Schacht  and  Biltz  *  therefore  inferred 
that  it  contained  alcohol,  and  their  prediction  that  such  was  the  case, 
without  even  having  seen  a  sample,  ultimately  proved  to  be  the  case. 
Moreover,  Schacht  ^  found  that  "chloroform  Pictet"  suffers  the  usual  de- 

^  Mon.  Sci.,  Mar.,  1882,  262.  Yvon  found  that  chloroform  prepared  according 
to  the  French  Pharmacopoeia  of  1866,  by  agitating  with  water,  leaving  in  contact 
with  potassium  carbonate,  drying  over  calcium  chlorid,  and  finally  rectifying,  is 
sufficiently  pure  for  anesthetic  purposes.  He  pointed  out,  however,  that  a  still 
purer  product  could  be  obtained  by  modifications  of  this  method. 

^  The  method  official  in  the  French  Pharmacopoeia  of  1899  for  the  purification 
of  commercial  chloroform  was  modified  by  Masson  (J.  pharm.  chim.,  9,  568),  ac- 
cording to  whose  process  crude  commercial  chloroform  is  first  washed  with  water, 
the  aqueous  layer  separated,  and  the  chloroform  shaken  with  2.5  per  cent  of  its 
weight  of  sulphuric  acid,  and  the  operation  being  repeated  with  a  fresh  portion 
of  acid,  if  necessary,  the  acid  being  left  in  contact  with  the  chloroform  for  two 
or  three  days.  The  chloroform  is  then  treated  with  3  per  cent  of  its  weight  of 
sodium  hydroxid  solution  (sp.  gr.,  1.33)  which  is  left  in  contact  also  for  two  or 
three  days.  It  is  then  washed  with  water,  dried  over  calcium  chlorid,  and  2.5 
per  cent  of  poppy  oil  added.  Distillation  is  then  conducted  into  graduated  re- 
ceivers containing  0.2  per  cent  by  weight  of  alcohol  for  the  amount  of  chloroform 
they  are  to  contain.  The  important  modifications  of  this  process  are:  the  pro- 
longed contact  of  the  chloroform  with  the  sodium  hydroxid  solution;  the  final 
distillation  over  poppy  oil  (it  was  then  employed  in  the  official  process  for  a  pre- 
liminary distillation)  ;  and  the  presence  of  a  trace  of  alcohol  in  the  receiver. 

The  "Chloroforme  Officinal"  of  the  present  Codex  (1908,  148)  is  prepared 
from  rectified  commercial  chloroform  by  agitating  with  distilled  water,  decant- 
ing and  filtering;  shaking  with  sulphuric  acid,  then  allowing  to  stand  over  sodium 
hydroxid;  drying  over  calcium  chlorid,  and  finally  distilling  over  poppy  oil  and 
adding  alcohol  (5/1000  part  by  weight  of  absolute  ethyl  alcohol). 

See  also,  Maillard  and  Eanc:     Compt.  rend.  Soc.  biol.,  61,  483. 

'  U.  S.  Patent  489,592,  1893;  and  English  Patent  15,514,  1891;  see  also  J.  Soc. 
Chem.  Ind.,  18,  231.  On  some  peculiar  phenomena  in  the  solidification  of  chloro- 
form, see  Pictet:  Compt.  rend.,  114,  1245. 

*J.  Soc.  Chem.  Ind.,  12,  543;    see  also.  Western  Drug.,  1891,  379. 

^  Pharm.  J.,  22,  No.  3,  691. 


APPENDIX    II  881 

composition,  on  washing  to  remove  alcohol ;  and  Biltz  ^  regarded  the 
decomposition  of  chloroform  under  the  influence  of  light  and  air  as  a 
natural  characteristic  of  chloroform,  and  not  as  a  result  of  impurities." 
However,  DuBois-Reymond  ^  stated  that  "chloroform  Pictet"  is  affected 
less  by  sunlight  than  any  other  chloroform  with  even  the  addition  of 
alcohol.* 

J.  F.  Macfarlane  &  Co.^  separated  the  following  relative  quantities 
of  "impurity"  from  "chloroform  Pictet"  and  a  British  product. 

From  domestic  product 0  0000512  per  cent. 

0.0002050     " 

"     "chloroform  Pictet"   0 .  0008200     " 

"  "  "       0.0004100     " 

The  "chloroform  Pictet"  examined  by  Baskerville  possessed  a  density 
of  1.491  at  15/15°  C,  and  all  the  tests  for  the  presence  of  impurities 
and  decomposition  products  gave  negative  results.  Four  other  German 
products  and  one  American  anesthetic  chloroform,  all  of  which  were 
purified  by  chemical  treatment,  were  found  to  be  fully  as  pure,  however, 
which  indicates  that  purification  by  cryogenic  means  is  not  necessary  to 
secure  chloroform  of  anesthetic  grade. 

DuBois-Eeymond  '^  has  studied  the  physiological  action  of  "chloro- 
form Pictet"  and  of  the  residue  of  foreign  substances  obtained  in  the 
process  of  Pictet.  He  found  that  the  shape  of  the  pulse  waves  and  the 
frequency  of  respiration  are  about  equally  affected  by  both  substances, 
the  rate  of  respiration  varying  freely;  that  the  pulse  rate,  compared  in 
nineteen  cases,  is  higher  at  the  close  of  the  experiments  with  the  residue 
than  with  those  with  the  purified  chloroform ;  that  the  blood  pressure  in 
by  far  the  greater  number  of  experiments  at  the  moment  respiration 
ceases  is  higher  after  inhalation  of  the  purified  chloroform  than  after  in- 
halation of  the  impure  residue ;  and,  finally,  that  the  residue  causes  stop- 
page of  respiration  much  more  quickly  than  does  purified  chloroform. 
DuBois-Reymond  conducted  hardly  a  sufficient  number  of  physiological 
experiments  to  enable  one  to  form  a  definite  opinion  of  the  physiologi- 
cal action  of  the  commonly  occurring  impurities  of  commercial  chloro- 
form which  are  separated  by  means  of  the  process  of  Pictet.  In  addi- 
tion the  variable  nature  of  these  impurities,  owing  to  the  various  proc- 

*  Ibid. 

'See  also,  Biltz:     Ber.  Pharm.  Ges.,  2,  76,  247;   Schacht:    Ibid.,  2,  69;   and 
Thilo :  Pharm.  Ztg.,  39,  543. 
^  Pharm.  Centralh.,  S2,  658. 

*  Had  DuBois-Eeymond  made  his  comparisons  of  '  *  chloroform  Pictet ' '  with 
properly  purified  samples  of  anesthetic  chloroform,  no  such  differences  as  he  re- 
ported would  have  been  observed. 

^Brit.  Med.  J.,  1892,  1,  525. 
^Brit.  Med.   J.,   1892,  1,  209. 


882  ANESTHESIA 

esses  of  manufacture  and  the  variability  of  the  crude  materials  used 
therein,  renders  such  an  investigation  of  little  value. 

When  acetone  is  used  for  the  preparation  of  chloroform,  it  should  be 
previously  purified/  and  this  purification  should  be  carefully  executed 
in  order  to  prevent  the  formation  of  condensation  compounds.^ 

It  has  been  stated  that  chloroform  made  from  acetone  is  not  nearly 
so  good  an  anesthetic  as  chloroform  made  from  ethyl  alcohol ;  ^  but  this 
opinion  is  based  upon  the  findings  of  Wade  and  Finnemore ;  *  that  chlo- 
roform prepared  from  ethyl  alcohol  contains  a  very  small  proportion  of 
ethyl  chlorid.  When  chloroform  is  properly  made  from  purified  acetone 
careful  purification  will  result  in  the  production  of  pure  chloroform.^ 

Gregory  ®  found  that  the  chloroform  prepared  from  ethyl  alcohol 
and  wood  spirit,  when  fully  purified,  is  quite  identical  in  all  its  proper- 
ties, but  that  from  the  former  is  more  easily  purified.  In  fact,  it  may 
be  asserted  on  the  authority  of  Brown,  Squibb,  Schacht,  and  Biltz '' 
that  properly  purified  chloroform  is  the  same  from  whatever  source  it  is 
obtained ;  however.  Cross  and  also  Spilsbury  ^  have  expressed  the  opin- 
ion that  chloroform  made  from  ethyl  alcohol  is  physiologically  safer 
than  that  from  methylated  spirit  and  acetone.     The  latter  opinion  is  a 

^  In  Am.  J.  Pharm.,  1889,  321,  is  an  account  of  a  method  for  purifying  ace- 
tone used  in  the  preparation  of  chloroform. 

*Dott  {J.  Soc.  Chem.  Ind.,  27,  272)  has  called  attention  to  the  importance 
of  the  impurities  which  may  be  present  in  commercial  acetone.  He  found  that 
samples  which  indicated  99  per  cent  by  the  iodoform  test  and  other  methods  gave 
about  7  per  cent  distilling  above  58°.  This  was  first  thought  to  be  due  to  the 
presence  of  higher  ketones  or  other  bodies  yielding  iodoform,  but  Gibson  sug- 
gested that  it  might  possibly  be  caused  by  the  presence  of  even  1  per  cent  of  a 
mixture  of  the  condensation  products  of  acetone  (e.  g.,  mesityl  oxid,  phorone,  and 
mesitylene),  which  all  have  relatively  high  boiling  points.  It  was  found  that, 
on  mixing  pure  acetone  with  1  per  cent  of  the  mixed  condensation  products,  it 
behaved  on  distillation  and  in  its  iodoform  yield,  and  otherwise,  like  the  samples 
referred  to.  When  purifying  acetone,  therefore,  manufacturers  should  avoid 
treatment  with  mineral  acids  or  other  method  which  is  likely  to  cause  formation 
of  the  condensation  compounds.  On  the  purity  of  acetone,  see  also  Guttman: 
Dingier' s  Polyt.  J.,  1894,  96;  Klar:  J.  Soc.  Chem.  Ind.,  1897,  722. 

^■Price:   Pharm.  J.,  23,  89. 

*Loc.  cit. 

"  J.  F.  MacFarlane  &  Co.  (Lancet,  1905,  1,  747)  have  expressed  the  opinion 
that  chloroform  prepared  from  acetone  is  by  no  means  generally  accepted  as  in- 
ferior to  chloroform  prepared  from  alcohol,  and  consider  that  up  to  the  present 
InsuflBcient  evidence  has  been  adduced  to  establish  the  view  that  it  is  actually 
inferior. 

We  may  state  here  that,  from  our  experience,  anesthetic  chloroform  manufac- 
tured from  acetone  has  been  found  by  American  anesthetizers,  to  be  fully  as 
satisfactory  as  that  from  other  sources. 

«Mon.  J.  Med.  Sci.,  May,  1850;   Pharm.  J.,  9,  580. 

'  Pharm.  J.,  24,  No.  3,  811. 

» lUd.,  29,  No.  4,  660. 


APPENDIX   II  883 

recent  one  (1909),  and  is  substantiated,  at  least  in  part,  by  other  evi- 
dence, but  is  totally  incorrect  when  the  chloroform  is  properly  purified.^ 

The  carbon  tetrachlorid  used  is  prepared  from  carbon  disulphid  (the 
electric  furnace  product),  and  manufacturers  in  the  United  States  state 
that  it  is  so  free  from  sulphur  compounds  that  "no  part  of  the  distillate 
separated  from  a  batch  of  5,000.  pounds  through  a  long  fractionating 
column  will  show  any  sulphur  compounds  by  the  most  delicate  tests 
known."  The  presence  of  carbon  disulphid  in  the  chloroform  produced  is 
guarded  against  by  means  of  a  process  for  removing  carbon  disulphid 
from  the  carbon  tetrachlorid  used;  when  traces  are  present  the  tetra- 
chlorid is  fractionated  in  a  high  column  still  until  the  distillate  will 
give  no  response  with  tests  for  the  presence  of  carbon  disulphid.  The 
distillate  is  considered  as  commercial  carbon  tetrachlorid,  which  is  usu- 
ally guaranteed  to  contain  99.7  per  cent  of  absolute  CCl^.  The  material 
remaining  in  the  still  is  tested  for  the  presence  of  carbon  disulphid,  and 
if  found  absent,  then  the  material  remaining  in  the  still  is  used  for  the 
manufacture  of  chloroform. 

The  Decomposition  of  Chloroform. — The  Changes  Which  Chlo- 
roform Undergoes  upon  Exposure  to  Air. — In  order  to  secure  a 
clear  conception  of  this  important  matter  it  is  desirable  to  compare  the 
conduct  of  "pure"  and  "anesthetic"  chloroform. 

In  1848  Morson  ^  found  that  "pure"  chloroform  undergoes  decom- 
position in  the  presence  of  light  and  air,  chlorin,  hydrochloric  acid,  and 
probably  other  "chlorin  compounds"  being  formed;^  later  he  observed 
that  the  decomposition  is  variable  in  extent  and  rapidity,  and  that  chlo- 
roform, when  kept  under  water,  does  not  decompose.*  Maisch,^  how- 
ever, stated  that  chloroform  containing  moisture  always  showed  the 
presence  of  "free  chlorin"  much  sooner  than  dry  samples. 

^  It  has  also  been  stated  that  headache  frequently  occurs  among  workmen 
while  bottling  chloroforta  made  from  methylated  spirit,  whereas  the  symptoms 
were  not  observed  while  manipulating  chloroform  derived  from  ethyl  alcohol  {ibid., 
18,  No.  4,  515).  In  this  connection  it  may  be  noted  that  in  one  works  where 
chloroform  has  been  made  from  carbon  tetrachlorid  for  eight  years,  according  to 
a  report  from  the  officers,  there  has  been  not  one  case  of  accidental  or  other  an- 
esthesia among  the  workmen. 

^Fharm.  J.,  8,  69. 

^  Therefore,  Morson  suggested  the  test  with  litmus  paper  and  purification  by 
repeated  agitation  with  distilled  water. 

^IMd.,  279.  In  1850  (see  Trans.  N.  Y.  Acad.  Med.,  1,  146)  it  had  been  ob- 
served in  this  country  that  chloroform  becomes  acid  and  contains  "chlorinated 
oils"  through  decomposition. 

^  Proc.  Am.  Pharm.  Assn.,  1867.  Chloroform  of  the  density  1.492,  dried  by 
means  of  calcium  chlorid,  was  kept  in  absolutely  dry  bottles  and  in  bottles 
slightly  moist,  then  both  kinds  were  exposed  to  diffused  daylight  and  to  direct 
sunlight.  Maisch  concluded  that  the  entire  absence  of  water  would  not  be  suffi- 
cient to  preserve  the  chloroform  unaltered. 


884  ANESTHESIA 

Hager/  investigating  the  question  more  extensively,  concluded  that 
"pure"  chloroform  is  not  decomposed  by  the  action  of  light  alone;  but 
that,  when  chloroform  is  exposed  to  the  action  of  the  sun's  rays,  it  be- 
comes decomposed,  exhibits  an  acid  reaction  to  test  paper,  and  there 
are  found,  among  its  products  of  decomposition,  hydrochloric  acid, 
"chloroxycarbonic  acid,"  ^  formic  acid/  and  free  chlorin.  Hager  first 
pointed  out  that  chloroform  is  decomposed  when  air  has  access  to  it, 
even  in  the  dark,  although  very  slowly.*  Eump  ^  made  similar  observa- 
tions, having  learned  that  protection  from  light  does  not  prevent  the  de- 
composition of  chloroform;  he  concluded  that  the  smallest  quantity  of 
moisture  and  air  will,  in  time,  induce  decomposition,  and  that  this,  once 
started,  proceeds  with  increased  rapidity.  Under  these  conditions,  by 
excluding  the  light,  Eump  found  that  carbonyl  chlorid  will  result. 

In  1883  Eegnault  ^  pointed  out  that  carbonyl  chlorid  is  the  most 
dangerous  impurity  found  in  chloroform,  and  stated  that  it  is  produced 
in  the  presence  of  light  by  the  action  of  air  on  chloroform.'^  In  col- 
laboration with  Eoux,  Eegnault  demonstrated  the  formation  of  carbonyl 
chlorid  from  chloroform  in  several  different  ways :  By  the  action  of  the 
spark  from  an  induction  coil  on  a  mixture  of  chloroform  vapor  and  air; 
by  allowing  air  saturated  with  vapor  of  chloroform  to  circulate  in  an 
effluve  apparatus ;  ^  and  by  the  action  of  ozonized  air.  The  last  experi- 
ment showed  that  the  production  of  carbonyl  chlorid  is  independent  of 
tlie  thermal  and  electric  phenomena  of  the  other  two,  and,  along  with 

^  Pharm.  Z.  Bussland,  Sept.,   1869. 

''Personne  found  that  samples  of  chloroform  liable  to  decomposition  always 
contain  ' '  chlorocarbonic  ether. ' '  It  has  also  been  maintained  that  the  change 
is  attributable  to  the  presence  of  allylene  bichlorid. 

'  Kappeler  ("  Anesthetica, "  173)  stated  that  formic  acid  and  aldehyd  are 
products  of  the  decomposition  of  chloroform. 

*  Hager  found  that  chloroform,  even  if  it  does  not  exhibit  an  acid  reaction, 
may  be  in  a  state  of  decomposition,  and  that  this  condition  may  be  detected  by 
the  reaction  such  chloroform  exhibits  with  ammonia,  Avhich  then  yields  with  it 
vapors  of  ammonium  chlorid. 

The  results  of  Hager 's  investigations  gave  rise  to  the  statement  which  has 
persisted  in  the  literature  till  to-day,  namely,  that  specimens  of  chloroform,  orig- 
inally of  good  quality,  on  keeping  become  impregnated  with  hydrochloric,  hypo- 
chlorous,  and  formic  acids. 

^Archiv.  Pharm.,  Oct.,  1874. 

'J.  Pharm.  Chim.,  5,  No.  5,  504. 

^  Eegnault  considered  the  accidental  presence  of  carbonyl  chlorid  common  at 
that  time. 

*  Eegnault  and  Eoux  found  that  nitrogen  charged  with  the  vapor  of  chloroform 
also  decomposes  the  chloroform  in  an  effluve  apparatus,  the  products  being  hy- 
drochloric acids  and  a  mixture  of  CgClo,  and  C^CIe.  Cf.  the  results  of  Besson  and 
Fournier  (Compt.  rend.,  150,  1118),  on  the  action  of  the  silent  discharge  on  chloro- 
form in  the  presence  of  hydrogen.  Among  the  chlorinated  derivatives  separated 
were  CC1«,  C^CU,  C^TLC\,  0,01,,  and  C^Cls. 


APPENDIX   II  885 

the  work  of  Eump,  established  the  formation  of  carbonyl  chloric!  during 
the  oxidation  of  chloroform.  Confirmation  of  this  was  later  had  from 
the  investigations  of  Marty  ^  and  Stark.^ 

Just  what  are  the  other  products  of  the  decomposition  of  chlo- 
roform is  a  question  which  has  received  considerable,  but  only  recently 
very  careful,  attention.  Brown  ^  found  that,  while  chloroform  is  not 
decomposed  by  the  action  of  sunlight  in  the  absence  of  oxygen,  it  is  so 
decomposed  when  oxygen  is  present,  yielding  as  products  chlorin,  car- 
bonyl chlorid,  and  water: 

4CHCI3  +  3O2  =  4COCI2  +  2H2O  +  201^: 
2COCI2  -f  2H2O  =  2CO2  +  4HC1. 

These  equations  have  been  recognized  as  correct  by  Schacht  and  Biltz,* 
and  by  Adrian ;  ^  but  Schacht  and  Biltz  considered  it  necessary  to  add 
that  they  apply  exclusively  to  the  decomposition  of  chloroform  which  is 
perfectly  free  from  alcohol.  That  the  decomposition  of  chloroform  is 
accelerated  in  an  atmosphere  of  pure  oxygen,  is  a  fact  which  Schacht 
and  Biltz  were  disposed  to  ascribe  to  the  absence  of  nitrogen. 

In  regard  to  the  ultimately  recognizable  results  of  the  oxidation  of 
chloroform  in  particular  instances — for  example,  in  the  case  of  anes- 
thetic chloroform — there  is  one  circumstance  which  exercises  a  decided 
determining  influence;  but,  as  indicated  by  Schacht  and  Biltz,^  it  is  not 
always  sufficiently  considered,  and  this  fact  has  given  rise  to  differences 
of  opinion  as  to  the  nature  of  this  decomposition  and  of  its  products. 
For  instance,  Eamsay  ^  advanced  the  opinion  that  the  only  products  of 
the  decomposition  of  chloroform  are  carbonyl  chlorid  and  hydrochloric 
acid,  while  Brown,  Schacht  and  Biltz,  and  Adrian  maintain  that  in 
addition  to  the  formation  of  those  products  there  is  also  an  elimination 
of  chlorin  in  the  free  state.  Schacht  and  Biltz  considered  that  this  dif- 
ference of  opinion  was  doubtless  to  be  ascribed  to  want  of  attention  to 

^L'Union  'pJiarm.,  Nov.,  1888.  Marty  found  that  "pure"  chloroform  did  not 
remain  unaffected  more  than  two  days  in  summer  or  5  days  in  winter,  when 
freely  exposed  to  air.  The  same  chloroform  remained  unaltered  for  15  months  in 
the  dark,  although  in  contact  with  air.  With  chloroform  containing  0.1  per  cent 
of  absolute  alcohol,  no  decomposition  resulted  even  after  an  exposure  of  15  months 
to  continuous  sunlight. 

^  Pharm.  J.,  20,  No.  3,  407.  Chloroform  exposed  to  diffused  sunlight  for 
five  months  contained  hydrochloric  acid,  carbonyl  chlorid,  and  an  "oily  hydro- 
carbon." According  to  Stark,  the  alarming  dyspnea  produced  by  some  samples 
of  chloroform  when  inhaled  is  probably  due  to  the  presence  of  carbonyl  chlorid. 

^Pharm.  Soc.  Ednh.,  March,   1893. 

^PJiarm.  J.,  1893,   1005. 

"J.  Pharm.  Chim.,  18,  5. 

'  Loc.   cit. 

''J.  Soc.  Chem.  Ind.,  11,  772.  The  same  view  was  held  by  Breteau  and  Woog: 
Conipt.  rend.,  143,  1193. 


886  ANESTHESIA 

the  presence  of  alcohol  in  the  chloroform  experimented  with/  and  to  the 
resulting  misinterpretation  of  the  chemical  changes  which  occurred. 
They  stated  that  they  had  succeeded  in  proving  that  the  well-known  in- 
fluence of  alcohol  in  preserving  chloroform  from  decomposition  ^  was 
due  to  the  alcohol  taking  up  and  chemically  combining  with  the  deleteri- 
ous products  resulting  from  the  decomposition,  so  as  to  render  them 
innocuous.  Later  ^  they  concluded  that,  though  the  direct  products  of 
the  decomposition  of  "pure"  chloroform  were  only  chlorin  *  and  carbonyl 
chlorid,  in  the  case  of  chloroform  containing  alcohol  the  chlorin  thus 
eliminated  acted  on  the  alcohol  present,  and  so  gave  rise  to  the  produc- 
tion of  hydrochloric  acid.  In  this  way  they  accounted  for  the  presence 
of  hydrochloric  acid  in  the  first  state  of  the  decomposition  of  anesthetic 
chloroform,^  and  considered  that  they  had  explained  the  point  which  had 
given  rise  to  dispute,  namely,  that  the  elimination  of  free  chlorin  is  a 
primary  feature  of  the  alteration.  These  views  led  to  a  controversy  with 
the  Browns,*'  and  the  formation  and  presence  of  free  chlorin  as  one  of 

^  See  Preservation. 

*  The  correctness  of  this  view,  which  has  been  generally  favored,  was  consid- 
ered in  Chapter  VII,  p.  290.  =*  Fliarm.  J.,  22,  No.  3,  1041. 

*  Popov  (J.  Huss.  Phys.-Cheni:  Soc,  7,  1061)  studied  the  influence  of  light  on 
chloroform  dissolved  in  linseed  oil,  finding  that  the  iodin  number  of  the  oil  was 
lowered,  owing  to  the  action  of  the  halogen  upon  the  unsaturated  compounds  of 
the  oil.  This  work  does  not,  however,  prove  that  chlorin  is  a  product  of  the 
photolytic  decomposition  of  chloroform. 

^  Of.  Laurent  (Ann.  chim.  phys.,  1837,  318)  who  found  that  chlorin  acts  on 
chloroform  in  the  sunlight,  forming  hydrochloric  acid  and  "CaClg. "  The  opinions 
of  Schacht  and  Biltz,  variously  expressed,  seem  to  embody  this  general  view: 
The  gradual  disappearance  of  free  chlorin  when  chloroform  is  undergoing  de- 
composition is  an  indication  of  its  further  action  on  the  chloroform,  producing 
hydrochloric  acid  and  altering  the  relative  proportions  of  carbonyl  chlorid  and 
hydrochloric  acid  so  as  to  increase  the  latter. 

"Schacht  and  Biltz  (Pharm.  J.,  23,  No.  3,  1005)  stated  that  "decomposition 
cannot  be  detected  in  alcohol-reduced  chloroform  until  all  the  added  alcohol  has 
been  consumed."  Brown  (ibid.,  24,  321)  found  that  "pure"  chloroform  to 
which  0.077  per  cent  of  alcohol  had  been  added,  when  exposed  to  direct  sunlight 
in  colorless  glass,  began  to  decompose  in  14  to  19  days.  He  found  that  after  de- 
composition had  been  recognized  by  zinc  iodid  and  starch,  as  well  as  by  baryta 
water,  reactions  were  obtained  with  1:2000  potassium  dichromate  solution  and 
the  iodoform  test,  and  these  were  ascribed  to  the  presence  of  alcohol.  Schacht 
(Ber.  pharm-.  Ges.,  Oct.,  1894)  defended  his  position,  and  stated  that  the  reac- 
tions obtained  were  not  produced  by  alcohol,  but  by  "chloric  ether"  and  "Phos- 
gene alcoholide. "  The  Browns  {Pharm.  J.,  25,  No.  3,  836)  maintained  that 
Schacht  had  not  proved  that  ethyl  chlorid  and  chloroformic  ether  are  produced 
in  the  decomposition  of  alcohol-reduced  chloroform,  and  that  they  give  reactions 
similar  to  alcohol.  On  the  other  hand,  they  considered  that  they  themselves  had 
proved  that  at  the  time  the  decomposition  is  first  recognized  by  means  of  zinc 
iodid  and  starch,  chlorin  has  not  been  produced  in  sufficient  quantity  to  com- 
bine with  all  of  the  added  alcohol,  and  that  ethyl  chlorid,  chloroformic  ether,  or 
carbonic  ether  do  not  give  reactions  which  could  be  mistaken  for  those  of  alcohol. 


APPENDIX   II  887 

the  decomposition  products  of  chloroform  containing  alcohol  were  by  no 
means  definitely  settled. 

Schoorl  and  Van  den  Berg^  conducted  quantitative  experiments 
which  seemed  to  indicate  that,  when  chloroform  is  decomposed  by  the  ac- 
tion of  light  in  the  presence  of  an  excess  of  oxygen,  carbon  dioxid,  water, 
and  chlorin  are  formed  in  accordance  with  the  following  equation : 

2CHCI3  +  50  =  3CO2  +  H2O  +  3C1, 
According  to  the  same  chemists,  when  insufficient  oxygen  is  present — a 
condition  usually  obtaining  in  practice — carbonyl  chlorid  and  hydrogen 
chlorid  are  jDroduced  in  molecular  proportions: 

CHCI3  +  0  =  HCl  +  COOL 
The  equations  given  by  Schoorl  and  Van  den  Berg  were  evidently  in- 
tended to  apply  to  the  decomposition  of  pure  chloroform,  and  the 
changes  which  occur  in  anesthetic  chloroform  were  not,  so  far  as  we  are 
aware,  considered.  Schoorl  and  Van  den  Berg^  confirmed  the  observa- 
tion that,  in  the  absence  of  air  or  oxygen,  chloroform  is  not  affected  by 
light  exposure. 

Finally  Dott  ^  has  suggested  that  the  formation  of  carbonyl  chlorid 
in  chloroform  very  probably  occurs  in  accordance  with  the  following 
equation : 

CHCI3  +  H2O2  =  COCI2  +  HCl  4-  H.O  * 

Baskerville  and  Hamor  concluded  from  their  experimental  results 
that: 

(1)  The  products  of  the  oxidation  of  pure  chloroform  are  carbonyl 
chlorid  and  hydrochloric  acid: 

CHCI3  4-  H,0  +  O2  =  COCL  +  HCl  +  H2O2 ; 
CHCI3  +  H2O2  =  COCL  +  HCl  -f  H2O 

They  were  convinced  that  oxidation  would  not  occur  if  water  were 
excluded,  and  the  absolute  exclusion  of  moisture  appears  to  be  impossi- 
ble. Hydrogen  dioxid  is  formed,  although  they  were  unable  to  detect  it 
in  chloroform  undergoing  oxidation,  and  therefore  concluded  that  its  ex- 
istence is  ephemeral,  and  oxidation  of  the  chloroform  continues  through- 
out the  period  of  exposure. 

The  decomposition  of  pure  chloroform  is  favored  by  a  degree  of 
moisture,  and  is  accelerated  by  light,  as  is  shown  by  a  comparison  of  the 
results  obtained  in  the  experiments  wherein  colorless  glass  was  used  with 

^Pharm.  WeeJcblad.,  42,  877. 

'Ibid.,  43,  8.  On  exposure  to  air,  in  the  absence  of  light,  chloroform  gave  no 
precipitate  with  silver  nitrate  even  after  four  hours,  whereas  bromoform  and  iodo- 
form after  one  hour  gave  distinct  indications  of  decomposition. 

V.  Soc.  Chem.  Ind.,  27,  272. 

*  Support  to  this  view  is  had  from  the  fact  that  conditions  which  favor  the 
formation  of  hydrogen  dioxid — a  degree  of  moisture  and  direct  sunlight — are  also 
those  which  favor  the  decomposition  of  chloroform. 


888  ANESTHESIA 

those  in  which  anactinic  glass  containers  were  employed.  Moreover,  car- 
bonyl  chlorid  is  always  formed  with  increased  readiness  in  the  presence 
of  acids. ^ 

The  extent  of  the  oxidation  is  dependent  upon  the  nature  of  the  con- 
tainer, the  amount  of  air  present,  the  purity  of  the  sample,  and  the  in- 
tensity of  the  light  to  which  it  is  exposed.  In  light  alone,  when  no  air 
is  present,  no  decomposition  occurs  for  ordinary  periods  of  exposure ;  and 
in  cases  where  there  is  air  contact  alone,  and  no  exposure  to  light,  the 
oxidation  is  slow. 

Free  chlorin  can  only  result  from  the  photochemical  decomposition  of 
carbonyl  chlorid:^ 

COCI2  =  CO  +  CL 
It  is  likely  that  in  the  cases  where  "chlorin"  was  identified  as  an  indica- 
tion of  incipient  alteration  of  chloroform  hydrogen  dioxid  was  the  cause 
of  the  reactions  observed.     No  chlorin  was  found  by  Baskerville  when 
containers  of  anactinic  glass  were  used. 

This  view  of  the  oxidation  of  pure  chloroform  is  supported  in  full  by 
the  analogous  case  of  the  photochemical  oxidation  of  iodoform,^  the  pri- 
mary products  of  which  are  carbonyl  iodid  and  hydriodic  acid,  free  iodin 
resulting  only  from  the  decomposition  of  the  carbonyl  iodid  and  from  the 
oxidation  of  the  hydriodic  acid. 

(2)  The  products  of  the  oxidation  of  anesthetic  chloroform  are  pri- 
marily the  oxidation  products  of  alcohol,  and  no  decomposition  of  chlo- 
roform itself  occurs  while  the  oxidation  of  alcohol  proceeds.  When  the 
oxidation  of  alcohol  reaches  a  maximum,  decomposition  of  the  chloro- 
form goes  on  as  in  the  case  of  pure  chloroform,  with  the  exception  that 
chlorinated  derivatives  of  the  oxidation  products  of  alcohol  may  result. 
The  decomposition  of  the  chloroform  itself  is  retarded  so  long  as  oxida- 
tion of  the  alcohol  proceeds,  and  the  retardation  is  consequently  depend- 
ent upon  the  amount  of  alcohol  present,  that  is,  the  alcohol  acts  as  a 
"negative  catalyst"  through  its  capacity  for  oxidation.  The  extent  of 
the  oxidation  is,  of  course,  subject  to  the  conditions  referred  to  as  ap- 
plicable to  "pure"  chloroform.     It  is  important  to  note,  however,  that 

^  Lowry  and  Magson,  Trans.  Chem.  Soc,  93,  121,  who  observed  that  the  forma- 
tion of  carbonyl  chlorid  is  evidently  accelerated  by  the  presence  of  acids. 

"In  this  connection,  see  Coehn  and  Becker:  Ber.,  43,  130;  and  Weigert:  Ann. 
Physik,  1907,  S4,  No.  4,  55.  The  influence  of  light  on  the  reversible  reaction, 
CO  +  Clj— ^^COCU,  is  purely  catalytic. 

'See  Plotnikow:  Z.  physikal  Chem.,  75,  337,  385.  According  to  this  investi- 
gator the  whole  reaction  is  as  follows:  CHI3  +  O  =  COI^  +  HI;  C0l2=:C0  + 
I,;  2HI  +  O  =  H,0  +  I2. 

In  the  light,  under  constant  conditions,  the  iodin  separated  is  proportional  to 
the  time,  and  if  the  illumination  is  removed  the  reaction  still  proceeds,  but  with 
reduced  velocity.  There  is  no  separation  of  iodin  in  the  absence  of  oxygen,  and 
none  in  a  benzene  solution  which  has  not  been  exposed  to  light. 


APPENDIX    II  889 

anesthetic  chloroform  always  contains  water,  the  usual  amount  being 
about  0.05  per  cent  by  volume,  according  to  our  experience. 

Verified  Tests  for  Purity  of  Anesthetic  Chloroform. — Odou. — Pure 
anesthetic  chloroform  possesses  a  characteristic  odor,^  and  such  chlo- 
roform volatilizes  entirely  without  disagreeable  or  foreign  odor.  The 
test  may  be  carried  out  as  follows:  One  hundred  c.  c.  of  anes- 
thetic chloroform  are  slowly  evaporated  over  a  water  bath  until  about 
10  c.  c.  remain  in  the  flask.  This  residuum  should  be  colorless  and 
possess  no  foreign  odor;  and,  when  it  is  allowed  to  evaporate  on  fil- 
ter paper,  there  should  result  no  odor  of  fusel  oil,  empyreumatic  mat- 
ter, or  other  substances  than  chloroform  and  ethyl  alcohol,  as  the  last 
portions  disappear.  If  a  decided  odor  is  imparted  to  the  filter  paper 
after  the  evaporation  of  the  residue,  or  if  any  foreign  odor  is  observed 
during  the  course  of  evaporation,  the  chloroform  should  be  rejected;  but 
for  further  information  may  be  tested  for  such  impurities  as  fusel  oil, 
chlorinated  derivatives  of  alcohol,  acetone  or  the  higher  alcohols,  ex- 
tractive matter,  etc. 

Eesidue. — When  100  c.  c.  of  anesthetic  chloroform  are  allowed  to 
evaporate  in  a  platinum  dish  at  -|-  100°  C,  there  should  be  left  no  weigh- 
able  residue.  In  every  case  this  should  be  determined  gravimetrically, 
and  not  by  vision.^ 

Specific  G-eavity. — The  specific  gravity  gives  a  good  indication  of 
the  strength  of  the  preparation,  that  is,  how  much  alcohol  is  present, 
and  otherwise  shows  the  purity  of  the  drug  to  a  much  less  degree.  The 
determination  should  preferably  be  made  with  a  pyknometer  at  -|-  15° 
C.^  Chloroform  is  very  sensitive  to  temperature  variation.  The  Mohr- 
Westphal  balance  will  serve  to  give  a  rapid  approximate  result,  but 
should  not  be  depended  upon  where  any  considerable  degree  of  accuracy 
is  desired.* 

^Passy  (Compt.  rend.,  116,  769)  made  comparative  experiments  on  the  odorous 
power  of  chloroform,  bromoform,  and  iodoform,  which  afforded  the  following 
sharp  results  in  millionths  of  a  gram: 

Chloroform 30.00 

Bromoform      2  to  5 

Iodoform     0.06  to  0.7 

*  White  (Pharm.  J.,  25,  No.  4,  540)  proposed  that  when  10  mils  of  chloroform 
are  allowed  to  evaporate  in  a  clean  glass  beaker  or  dish,  which  is  afterward  heated 
on  a  water  bath,  there  should  be  left  no  visible  residue. 

*  The  form  of  pyknometer  designed  by  Perkin  (J.  prakt.  CJiem.  N.  F.,  SI,  486) 
is  very  suitable,  although  the  Sprengel  pyknometer  is  satisfactory. 

*  Water.  When  10  c.  c.  of  anesthetic  chloroform  are  agitated  with  10  c.  c.  of 
paraffin  oil  (sp.  gr.,  0.880)  there  should  be  perfect  solution  and  no  turbidity  pro- 
duced. This  shows  0.1  per  cent,  but  not  traces,  of  water.  The  water  per  se  is  not 
objectionable,  but  its  presence,  provided  air — that  is,  oxygen — is  present,  facili- 
tates decomposition  in  storage.  For  the  detection  of  smaller  amounts  of  water, 
use  calcium  carbid.    See  Baskerville  and  Hamor:     Loc  cit. 


890  ANESTHESIA 

Okganic  Impurities. — When  20  c.  c.  of  anesthetic  chloroform  are 
mixed  with  15  c.  c.  of  concentrated  sulphuric  acid  in  a  glass-stoppered 
vessel  of  50  c.  c.  capacity  which  has  been  previously  rinsed  with  concen- 
trated sulphuric  acid,  no  visible  coloration  should  be  imparted  to  the 
mixture  after  the  addition  of  0.4  c.  c.  of  pure  40  per  cent  formaldehyd 
solution,  and  then  shaking  throughout  a  period  of  five  minutes.^ 

Acetone. — Anesthetic  chloroform  should  give  a  negative  reaction  in 
all  cases  when  the  following  exclusion  test  is  applied: 

Ten  c.  c.  of  the  sample  are  agitated  with  5  drops  of  a  0.5  per  cent 
sodium  nitroprussid  solution  and  2  c.  c.  of  ammonium  hydroxid  (sp. 
gr.  =  0.925),  and  the  mixture  is  then  allowed  to  stand  for  several  min- 
utes. Chloroform  containing  up  to  1  per  cent  of  alcohol  may  impart  a 
yellowish  brown  color  to  the  supernatant  liquid  on  agitation,  but  when 
acetone  is  present  an  amethystine  color  results.  This  test  must  be  con- 
ducted in  the  cold.  After  application  to  the  suspected  chloroform  direct, 
the  first  10  per  cent  distillate  and  the  10  per  cent  residuum  obtained 
by  allowing  100  c.  c.^  of  the  sample  to  slowly  distil  should  be  tested. 

AcETALDEHYD. — When  10  c.  c.  of  anesthetic  chloroform  are  agitated 
with  10  c.  c.  of  water  and  5  drops  of  ISTessler's  reagent  U.  S.  P.,  and  the 
mixture  is  then  allowed  to  stand  for  5  minutes,  there  should  result  no 
precipitate,  and  the  reagent  should  assume  no  coloration,  although  it 
may  become  opalescent  or  slightly  turbid. 

Acidity. — When  20  c.  e.  of  anesthetic  chloroform  are  thoroughly 
agitated  with  10  c.  c.  of  water  and  2  drops  of  phenolphthalein  solution, 
and  then  titrated  with  !N"/100  potassium  hydroxid  solution,  added  drop 
by  drop,  not  more  than  0.2  c.  c.  of  standard  alkali  solution  should  be  re- 
quired to  produce  a  faint  but  decided  alkaline  reaction  permanent  for  15 
minutes,  when  the  mixture  is  shaken  30  seconds  after  the  addition  of 
each  drop  of  alkali.  If  the  presence  of  free  acid  is  indicated,  the  sample 
should  be  rejected,  but  for  further  information  may  be  examined  for  the 
oxidation  products  of  pure  chloroform  (carbonyl  chlorid,  hydrogen  chlo- 
rid)   and  alcohol. 

The  Decomposition  Products  of  Anesthetic  Chloroform. —  (a) 
The  detection  of  acetaldehyd  is  referred  to  above; 

^  The  reasons  for  this  test  are  given  in  full  in  the  paper  by  Baskerville  and 
Hamor:     Loc.  cit. 

*When  the  proportion  of  acetone  to  chloroform  is  1:  500,  the  amethyst  color 
is  marked;  but  in  the  presence  of  1  part  in  1,000  the  coloration  is  not  distinct 
until  the  mixture  of  chloroform  with  ammonium  hydroxid  and  sodium  nitro- 
prussid has  been  saturated  with  ammonium  sulphate,  shaken,  and  then  allowed  to 
rest  for  five  minutes.  It  is  advisable,  in  all  cases,  to  run  a  blank  test  on  pure  an- 
esthetic chloroform  for  comparison.  Since  acetaldehyd  is  generally  present  in 
fresh  and  properly  stored  samples  of  anesthetic  chloroform  in  proportions  greater 
than  1:  3300,  usually  the  reaction  is  not  interfered  with  by  this  substance;  but  in 
every  case  the  sample  should  be  examined  for  the  presence  of  acetaldehyd. 


APPENDIX    II  891 

(b)  Anesthetic  chloroform  failing  to  comply  with  the  above  acidity 
test,  and  which  contains  no  carbonyl  chlorid  or  hydrogen  chlorid,  should 
be  rejected,  since  then  the  indication  is  that  acetic  acid  is  present; 

(c)  When  20  c.  c.  of  anesthetic  chloroform  are  shaken  during  20 
minutes  with  15  c.  c.  of  concentrated  sulphuric  acid  in  a  glass-stoppered 
tube  of  50  c.  c.  capacity  previously  rinsed  with  sulphuric  acid,  and  2  c.  c. 
are  diluted  with  5  c.  c.  of  water,  the  liquid  should  remain  colorless  and 
clear,  and  should  possess  no  odor  foreign  to  anesthetic  chloroform  (chlo- 
roform and  alcohol) ;  and  the  liquid  should  still  retain  its  transparency 
and  colorless  state  when  further  diluted  with  10  c.  c.  of  water,  and  the 
transparency  should  not  be  diminished  on  the  addition  of  5  drops  of  sil- 
ver nitrate  solution.  A  positive  result  is  indicative  of  the  presence  of 
chlorinated  derivatives  of  the  oxidation  products  of  alcohol,  etc. 

Degrees  of  Purity  of  American  Chloroforms. — The  main  impurities 
contained  in  American  anesthetic  chloroforms  are,  besides  water,  im- 
purities decomposable  by  sulphuric  acid  and  traces  of  the  oxidation 
products  of  ethyl  alcohol.  The  presence  of  small  amounts  of  ethyl  alco- 
hol is  necessary;  but  anesthetic  chloroform  should  contain  but  mere 
traces  of  water,  and  it  is  desirable  that  it  be  absolutely  water-free.  The 
necessary  precautions  should  be  taken  by  manufacturers  to  guard  against 
the  presence  of  organic  impurities  as  well  as  of  extractive  matter — a 
common  contaminant  of  anesthetic  chloroform  contained  in  unprotected 
cork-stoppered  bottles. 

The  table  (p.  893)  will  serve  to  show  the  comparative  purity  of 
various  samples  of  chloroform.  Nos.  1-9  were  samples  of  anesthetic 
chloroform,  supposed  to  be  of  the  present  U.  S.  P.  grade  and  such  as  are 
now  being  supplied  to  the  trade  ;^  No.  10  was  a  sample,  stated  to  be  of 
U.  S.  P.  quality,  contained  in  a  tin  and  17  months  old;  ISTo.  11  was  a 
sample  of  "Chloroform  for  Anesthesia"  contained  in  a  sealed  tin,  and  6 
years  old;^  and  No.  12  was  an  unopened  tin  of  "chloroformum  purifi- 
catum,"  manufactured  in  1863  or  shortly  before.^  The  last  two  samples 
are  of  particular  interest,  since,  so  far  as  the  aixthors  are  aware,  they 
were  the  oldest  samples  of  chloroform  ever  examined. 

^All  of  these  samples,  with  the  exception  of  No.  6,  were  manufactured  in  the 
United  States.  These  samples  were  obtained  through  the  courtesy  of  the  various 
manufacturers,  to  whom  the  authors  desire  to  acknowledge  their  indebtedness. 

^  Sample,   dated  Nov.  1,  1905,  supplied  by  Surgeon-General  Torney,  U.  S.  A. 

^  This  sample  was  also  furnished  by  Surgeon-General  Torney  who  stated  that 
this  chloroform  was  taken  out  of  a  pannier  of  the  variety  issued  during  the  Civil 
War,  along  with  records,  etc.,  which  bore  the  date  of  1863.  To  quote  from  his 
letter  of  transmittal,  ' '  I  presume  that  the  chloroform  was  made  at  that  period,  or 
before,  and  I  may  say  that  it  is  the  last  survivor,  so  far  as  I  know,  of  the  chloro- 
form supplied  at  that  period."  It  is  important  to  note  that  this  tin  of  chloro- 
form possessed  a  smaller  air  space  than  No.  11,  the  container  being  almost  full; 
this  accounts  for  the  difference  in  oxidation  of  the  alcohol  in  the  two  samples. 


COMPARATIVE  PURITY  OF  VARIOUS  SAMPLES  OF  CHLOROFORM 

All  samples  gave  tests  for  water  present  in  permissible  amounts;  negative  acidity  tests,  U.  S.  P. 
negative  tests  for  chlorides  and  for  oxidation  products  of  pure  chloroform. 


No.  Source.                        Grade. 

1  Acetone Anaesthetic .  . 

2  Acetone Anaesthetic .  . 

3      Ansesthetic .  . 

4  Acetone AuEesthetic .  . 

5  Acetone Ansesthetic .  . 

6  Chloral Ansesthetic .  . 

7  Acetone Ansesthetic .  . 

8  Acetone Anaesthetic .  . 

9  Carbon  tetrachloride .  .  .  Ansesthetic .  . 

10      Ansesthetic .  . 

11  Acetone Ansesthetic .  . 

12  Alcohol Ansesthetic .  . 

13  Acetone Analytical .  .  . 

14  Acetone Commercial. . 


Density  at  25/25 


Odor. 


Residue  in  gm,  per  Uter. 


1.4827 

Normal 

1.4730 

Normal 

None 

1.4772 

Normal 

None 

1.4806 

Normal 

None 

1.4770 

1.4839 

Normal 

1.4756 

Normal 

1.4750 

Normal 

1.4773 

Normal 

1.4751 

Slightly  pungent. . 

0.0220 

1.4722 

Normal 

None 

1.4747 

Fruity 

1.4752 

Normal 

0.0165 

1.4846 

Normal 

0.0705 

No. 


Extractive  matter. 


Sulphuric 
acid  test. 


Formalin- 
sulphuric 
acid  test. 


1  Present  from  cork Faint Faint  brown .  .  . 

2  Absent Negative ....    Faint  yellow .  .  . 

3  Absent Negative.  .  .  .    Marked  brown. 

4  Absent Negative ....    Negative 

5  Absent Negative ....    Brown  color .  .  . 

6  Present  from  luting ....    Marked 

7  Present  from  cork Decided 

8  Indefinite Faint Very  faint  yellow 

9  Trace Very  faint .  .  .   Faint  yellow .  .  . 

10  Trace Faint 

11  Absent Marked 

12  Present Pronounced 

13  Present  from  cork Faint 

14  Present Marked 


Absolute  ethyl 

alcohol  in  c.  c. 

per  100  c.  c. 

0.50 
0.97 
0.77 
0.56 
0.70 
0.30 
0.80 
0.84 
0.74 
0.84 
0.83 
0.60 
0.69 


Higher  alcohols. 

Not  detected 
Not  detected 
Not  detected 
Not  detected 
Not  detected 
Not  detected 
Not  detected 
Not  detected 
Not  detected 
Not  detected 
Present 
Propyl 
Not  detected 
Not  detected 


No. 

Acetone. 

Acetaldehyde. 

Acetic  acid 

in  gm. 
per  100  c.  c. 

1 

Absent 

0  0003 

2 
3 

4 

.5 

Absent 

Not  detected 

Not  detected 

Trace. .. 

Trace .  .  . 

Trace .  .  . 

0.0001 
Absent 

6 
7 
8 
9 
10 
11 

Not  detected 

Not  detected 

Not  detected 

.  .  .    Trace .  .  . 
.  ..    Trace..  . 
...    Trace .  .  . 
...   Absent. . 
...    Present . 

:3300 

0.00015 
0.00015 
0.00030 
Absent 
0.00045 
0  0009 

12 

1  :  2000 

0  00045 

13 
14 

Not  detected 

Not  detected 

Trace... 

. ...   Trace... 

"Odorous  "Chlorinated 

decomposition  decomposition 

products."  products." 

Absent Absent 

Absent Absent 

Absent Absent 

Absent Absent 

Absent Absent 

Faint  reaction ....  Trace 

Absent Very  faint  reaction 

Absent Present 

Absent Absent 

Absent Present 

Absent Present 

Present Absent 

Absent Faint  reaction 

Absent Faint  reaction 


892 


APPENDIX    III 

OXYGEN 

History  of  Oxygen. 

Methods  of  Manufacturing  Medicinal  Oxygen. 
Impurities  That  May  Be  Present  in  Oxygen. 
Purity  of  Commercial  Medicinal  Oxygen. 
Standards  of  Purity  That  Should  Be  Eequired  for  Oxygen  to 
Be  Used  in  Medicine. 

History  of  Oxygen. — The  alchemists^  were  probably  acquainted 
with  oxygen,  perhaps  also  the  Greeks  ^  in  the  fourth  century,  and  the 
Chinese/  long  before  Priestley's  experiments.  In  1630  Jean  Eey  * 
knew  that  certain  metals,  when  heated,  fix  a  portion  of  the  air,  and  in 
1674  Mayow  ^  prepared  oxygen  from  niter.  In  1771  Scheele  ^  prepared 
a  gas  by  heating  several  oxids,  including  the  black  oxid  of  manganese, 
and,  at  about  the  same  time.  Cavendish  '^  studied  oxygen.  To  Priestley,^ 
however,  has  been  given  the  honor  of  discovering  oxygen  as  a  constitu- 
ent of  the  air.  Davy  ^  and  Lavoisier  ^°  later  studied  the  preparation  and 
nature  of  this  gas. 

Methods  of  Manufacturing  Medicinal  Oxygen. — At  the  present 
time  there  are  the  following  methods  of  preparation  and  manufacture  of 
oxygen  :^^ 

^Bolton:     Am.  Chem.,  4,  170. 

^Hoefer:     "Histoire  de  la  Chimie,"  2,  271. 

'Duckwood:     Chem.  News,  53,  250. 

*  Jean  Key :  ' '  Essai  sur  la  recherche  de  la  cause  pour  laquelle  1  'airain  et  le 
plomb  augmentent  de  poids  quand  on  les  calcine, ' '  Bazas,  1630. 

®  Mayow,  Eodwell :     Chem.  News,  8,  113. 

®  Scheele :  ' '  Chemische  Abhandlung  von  der  Luf  t  und  dem  Feuer, ' '  Upsala  u. 
Leipzig,  1777. 

^Cavendish:      Trans.  Boy.  Soc.,  56,  432;    74,  119,  170;  75,  372. 

» Priestley:  Ibid.,  62,  147;  65,  384;  73,  398;  75,  279;  78,  147,  313;  79,  7,  289; 
"Experiments  and  Observations  on  Different  Kinds  of  Air,"  London,  1775-1777, 
2,  29 ;  3,  1 ;  "  Experiments  and  Observations  Eelating  to  Various  Branches  of 
Natural  Philosophy,"  London,  1779,  1,  192. 

^  Trans.  Boy.  Soc.,  101,  1. 

^"Crell:  Chem.  J  own.,  4,  440;  5,  125;  Chem.  Ann.,  1786,  1,  33,  136; 
1778,  1,  354,  441,  528,  552;  1788,  2,  55,  262,  431,  433;  1789,  1,  145,  162,  260,  323; 
2,  68,  145,  433;  1790,  1,  69,  518;  1791,  1,  71;  1803,  1,  29. 

"  Baskerville  and  Stevenson  (/.  Ind.  Eng.  Chem.,  1911,  3,  No.  7)  made  an 
elaborate  investigation  on  this  subject.  For  details  of  procedure  and  methods 
used,  this  paper  should  be  consulted. 

893 


894 


ANESTHESIA 


(1)  Heating  chlorates;  (2)  heating  chlorates  with  various  sub- 
stances; (3)  from  hypochlorites,  and  reaction  of  chlorin  and  water;  (4) 
heating  sulphuric  acid  or  sulphates;  (5)  heating  various  solids  and  mix- 
tures. (MnOg,  CuB^O^,  etc.);  (6)  combustion  of  solid  mixtures  (chlo- 
rates with -combustible  material,  alkaline  peroxids  with  hydrated  salts, 
etc.) ;  (7)  reaction  of  peroxids  ("oxone")  with  water  and  aqueous  solu- 
tions; (8)  by  electrolysis  of  water;  (9)  from  the  air  by  means  of  mer- 
cury, cuprous  chlorid,  barium  dioxid;  manganates,  plumbates,  or  living 
matter;  dialysis  or  absorption;  (10)  from  liquid  air. 

For  medicinal  purposes  oxygen  is  manufactured  according  to  methods 
3,  7,  8,  and  10. 

Impurities  That  May  Be  Present  in  Oxygen. — The  following  sorts 
of  matter  may  be  suspected  to  exist  in  a  cylinder  of  oxygen  gas : 

(1)  Solids;  (2)  liquids;  (3)  gases  and  vapors:  HgO;  halogen  acids, 
HJSTOj,  organic  acids;  O3,  NOg,  ^2^3,  SOo;  NH3,  organic  bases;  CO2, 
halogens,  oxids  of  chlorin;  KCN,  (CN),;  PH3,  SbHg,  AsHg,  H^S;  H^; 
CO1CH4,  organic  matter;  Ng?  ^2^>  rare  gases  of  the  atmosphere. 

If  the  method  by  which  the  oxygen  has  been  prepared  is  known,  a 
consideration  of  many  of  these  impurities  is  unnecessary.  For  example, 
impurities  M^hich  exert  a  distinctly  injurious  physiological  action  are  not 
to  be  suspected  in  oxygen  prepared  by  electrolysis,  liquid  air,  or  the  de- 
composition of  alkaline  peroxids  (NagOa)  by  water.  It  is  only  neces- 
sary to  know  the  percentage  of  actual  oxygen  present  in  the  gas.  This 
may  be  determined  most  conveniently,  and  with  sufficient  accuracy,  by 
absorption  in  alkaline  pyrogallate  solution.  Care  should  be  taken  to  use 
an  alkali  produced  electrolytically  or  HempePs^  precaution  to  prevent 
the  production  of  carbon  monoxid.  Nitrogen  and  the  inert  noble  gases 
of  the  air  are  determined  by  difference. 

Purity  of  Commercial  Medicinal  Oxygen. — One  of  us  (C.  B.)^  has 
devised  elaborate  methods  for  the  examination  of  oxygen  and  determined 
the  purity  of  "C.  P."  oxygen  offered  on  the  market  for  medicinal  use. 
Below  is  given  a  tabulation  of  the  results  of  analyses,  according  to  these 
methods,  of  seven  makes  of  oxygen. 


Organic 

N2 

All  other 

fo. 

Source  of  oxygen 

O2     H2O 

CO2 

H2    Matter 

etc. 

impurities. 

1 

KCIO3  +  MnOj 

93.20  0.30 

0.11 

0           0 

6.39 

0 

2 

KCIO3  +  Mn02 

98.31  0.14 

present 

0          0 

1.54 

0 

3 

KCIO3  +  MnOz 

92.82  0.26 

trace 

0          0 

6.92 

0 

4 

KCIO3  +  Mn02 

97.13  0.23 

present 

0     trace 

2.63 

0 

5 

Liquid  air 

96.10  0.15 

0.01 

0          0 

3.74 

0 

6 

Electrolysis 

99.23  0.35 

9.03 

0.14     0 

0.25 

0 

7 

Na202    +H2O 

99.20  0.50 

trace 

0          0 

0.30 

0 

These  were  all  medicinally  pure. 

*"Gas  Analysis,"  English  translation  by  Dennis,  1906,  149. 
^  In  conjunction  with  Stevenson,  loc.  cit. 


APPENDIX    III  895 

Standards  of  Purity  That  Should  Be  Required  for  Oxygen  to  Be 
Used  in  Medicine. — The  gas  should  be  neutral  toward  moist,  delicate 
litmus  paper  (showing  absence  of  irritating  acid  or  alkaline  gases)  ;  and, 
when  passed  through  an  aqueous  solution  of  silver  nitrate,  it  should  pro- 
duce no  turbidity  (absence  of  chlorin  or  chlorin  oxids).  Not  more  than 
an  opalescence  should  be  produced  when  2  liters  of  the  gas  are  passed 
slowly  through  an  aqueous  solution  of  barium  hydroxid  (showing  mini- 
mum of  carbon  dioxid).  This  condition  is  to  be  modified  when  a  mix- 
ture of  oxygen  and  carbon  dioxid  (4  per  cent  of  the  latter)  is  deliber- 
ately used.  See  Chapter  II.  When  5  liters  of  the  gas  are  passed  slowly 
through  an  aqueous  solution  of  sodium  hydroxid,  then  over  heated  cop- 
per oxid,  and  finally  through  an  aqueous  solution  of  barium  hydroxid,  no 
turbidity  should  be  produced  (showing  absence  of  organic  impurities,  as 
hydrocarbons).  The  gas  should  contain  at  least  95  per  cent  oxygen  upon 
the  dry  basis.  As  supplied  for  use,  the  gas  should  contain  no  liquids  and 
no  solids. 


INDEX 


Abdomen,  effect  of  shock  on,  385 
ether  irrigation   of,    672-674 
local    anesthesia   of,    516-519 
Abdominal     distention,     effect     of     re- 
breathing  on,  113 
in  colonic  ether  anesthesia,   436 
Abdominal  operations,  shock  in,  403 
under  anoci-association,  407 
under   chloroform,   314 
under  local  anesthesia,  488,  519 
under     spinal     analgesia,     560,     586, 
587,   597 
site  of  injection  for,  612 
Abdominal    spasm    during    anesthesia, 

381 
Abernathy  on  the  anesthetist  as  a  spe- 
cialist,  676 
Abortion,  due  to  electric  analgesia,  635 
Abraham,    on    purification    of    chloro- 
form,  878 
Abscess  of  the  lung,  anesthesia  in,  329 
oral,  injection  into,  contra-indicated, 
546,  547 
A.  C.  mixture,  Sansom's,  809,  810 

Schafer  and  Scharlieb's,  810 
Acapnia,   406-409 

as  cause  of  death  under  ether  anes- 
thesia,  193 
as    cause    of    shock,    401.      See   also 

Vasomotor    activity 
prevention  of,  112,  409 
A.  C.  E.  mixture,  688,  689,  703 
administration  of,   142 
early  use  of,  23 
statistics  for,  843,   855 
Acetaldehyd,  689 

in  chloroform,   286,   890 
in  ether,  866,  867 
Acetate  lactic  in  spinal  analgesia  solu- 
tion, 603 
Acetic  acid,  impurities  in  ethyl  chlorid 
due  to,  253 
in   chloroform,   285,   286,    891 
Acetic  ether,  736.     See  also  Ethyl  ace- 
tate 
Acetoform,   689 
Acetone,    689 

methods   of    testing   chloroform   for, 

890 
preparation  of  chloroform  from,  285, 
874,    875,    882 
Acetone-chloroform,  724,  772.     See  also 

Chloretone  and  Methaform 
Acetonuria,  after  ether  anesthesia,  198 
See  also  Chloroform  poisoning 


897 


Acetyl    chlorid,    presence    of,    in    ethyl 

chlorid,   253 
Acetylene,   689,   690 
Acetylene   dichlorid,   733 

See  also  Dioform 
Acetylene   tetrachlorid,    831.      See  Tet- 

rachlorethane 
Acid  intoxication  due  to  ether,  413 

post-anesthetic,  70 

symptoms  of,  415 

treatment  for,  414 

See  also  Chloroform  poisoning 
Acids,    method    of    testing    chloroform 
for,   890 

method  of  testing  ether  for,   866 
Acidum      amidobenzoicum      aethylatum. 

See  Anesthesin 
Acoin,   540,   690,  691 

in  spinal  analgesia,  563,  599 
Acoincocain.     See  Acoin 
Acoin   oil,    691 
Acoinol,   691 
Adenoid  and  tonsil  cases,   340-352 

after-treatment  of,  345 

anesthesia  in,  341 

death  due  to  unskilful  anesthesia  in, 
336 

nasal  nitrous  oxid-oxygen   anesthesia 
in,    173 

results  in,  due  to  lack  of  preliminary 
medication,   369,   370 

sequestration-anesthesia  in,   470,   474 

technique  of,  344,  345 

upright  position  for,  345-352 

use  of  ethyl  chlorid  in,  268 

use  of  nitrous  oxid  in,  140 
Adenoid  operations,  ether  in,  247 

under     oil-ether     colonic     anesthesia, 
465 

use  of  Junker  apparatus  in,  322 
A-diehlorethane,    750 
Adralgin,  691 
Adralgin  chirurgicum,  691 
Adralgin   dentale,  691 
Adrenalin,  691,  692 

combined    with    novocain,    in    dental 
anesthesia,  540-542 

in  anesthesia  of  scalp,  497 

in  local  anesthesia,  478 

in    preparation    of    cocain    solutiona, 
539,   540 

in    spinal    analgesic    solutions,    576, 
599 

with  chloroform,  373 

with  cocain,  480,  481,  691 


898 


INDEX 


Adrenalin   hydrochlorid  in  spinal  anal- 
gesia,  601 
Adrenalin-Kokain-Tabletten,    691 
Adrenals,  effects  of  cldoroform  on,  304 
Adrenin   with    saline   in    shock   preven- 
tion, 403,  404 
Adrian"  on     decomposition    of    chloro- 
form, 885,  886 
Adrecain,  691 

Adrin  and  cocain  tablets,  691 
Aeration    of    lungs    during    anesthesia, 

376 
-^ther  anaestheticus  aranii,   691,  692 
j^ther  aneestheticus  Kiinig,  691 
Mther  anaestheticus  Wiggers,   692 
^ther     chloratus.       See   Ethyl  chlorid 
JEther    hydrocJiloricus    seu    muriaticus, 

250.     See  also  Ethyl  chlorid 
^ther  pro   narcosi,   861 
^ther  purificatus,   861 
^ther  vitrolique,  860 
^tho-methyl,   692 
^thoxycaffein,  692 
-^thylenum   ehloratum.      See   Ethylene 

chlorid 
^thylis   aminobenzoas,    737,   738 
^thylium  amidobenzoicum.     See  Anes- 

thesin 
^thyloform,    692 
jiEthylum    ehloratum,     250.      See    also 

Ethyl  chlorid 
After-treatment  for  adenoid  and  tonsil 
cases,  345 
in  intravenous   anesthesia,   530-532 
in  oil-ether  colonic  anesthesia,  463 
in  ordinary  cases,  378,  379 
Age  in  relation  to  spinal  analgesia,  591 
in  resistance  to  surgical  shock,   383, 

384 
influence  of,  in  hypnotism,  655 
selection    of    anesthetic   with    regard 
to,  326-328 
Aged,  ethyl  chlorid  anesthesia  in,  268 
nitrous    oxid    anesthesia    contra-indi- 
cated in,  136 
Air,     administration     of    nitrous    oxid 
with,  142,  143 
in  definite  amounts,  141 
in  unknown   quantities,  140,   141 
as  an  anesthetic,  692 
as  vehicle  in  colonic  ether  anesthesia, 

452 
comparative  value  of  oxygen  and,  81, 

82,  83 
effect    of,    on   chloroform,    290,    883- 

889 
ethyl  chlorid  and,  276 
insufflation  of,   as  a  method  of  arti- 
ficial respiration,  432 
following  intratracheal   anesthesia, 
429 
preparation  of  oxygen  from,  894 
Air  passages,  obstruction  of,  in  nitrous 

oxid-oxygen   anesthesia,   168 
Airway,     artificial,    in     surgical    anes- 
thesia, 390  ■ 


Airway,   free,   method    of   maintaining, 
361,  362 
maintenance  of,  by  artificial  respira- 
tion, 393 
in  intravenous  anesthesia,  529,  530 
with  breatliing  tubes,  390,  392 
obstruction  in,  due  to  shock,  389 
open,  maintenance  of,  in  ether  anes- 
thesia, 233 
Albuminuria,     absence     of,     in     ethyl 
chlorid  anesthesia,   265 
in  anesthesia,  61 
in  ether  narcosis,  190 
post-chloroformic,  absence  of,  follow- 
ing sequestration  anesthesia,  472 
Alcohol  as  preservative   of   chloroform, 
283,  285,  290,  291,  295 
in  A.  C.  E.  mixture,  688,  689 
in  anesthetic  block  for  shock  preven- 
tion, 406 
in  ether,  oxidation  of,  182 
in    preparation    of    chloroform,    873, 

874 
in    preparation    of    ether,    860,    861, 

862 
in  preparation  of  ethyl  chlorid,  252 
in  spinal  analgesic  solutions,  599,  603 
presence  of,  in  chloroform,  878 
preservative   influence  of,   on   chloro- 
form, 886 
test  for,  in  ethyl  chlorid,  257 
Alcohol  oxidation  in  chloroform  agita- 
tion, 296 
Alcohol   phenicum.      See    Carbolic   acid 
Alcohol     trichloramidoethylique.        See 

Chloralformamid 
Alcoholic  muriatic  ether,  251 
Alcoholics,    administration    of    nitrous 
oxid  in,  140 
choice  of  anesthetic  in,  329 
colonic  ether  anesthesia  in,  437 
ethyl  chlorid  anesthesia  in,  262,  269 
oil-ether  colonic  anesthesia  for,  461 
preliminary  medication  in  anesthetiz- 
ing, 371,  372 
sequestration  anesthesia  in,  473 
under  spinal  analgesia,  626 
use  of  ethyl  chlorid,  ether,  and  oxy- 
gen in,  278 
Aldehyd  in  anesthetic  ether,  183,  869 

in  chloroform,  285 
Aldehyds,  compounds  of,  with  hydrogen 

chlorid,  253 
Alden's     auto-operation    under     spinal 

analgesia,  580 
Alessandri   on  postoperative   effects   of 

stovain  analgesia,  582,  583 
Alexander   and    Gwathmey   on   adenoid 

and  tonsil  cases,  340-352 
Alimentary  lesions,   colonic  ether  anes- 
thesia   contra-indicated    in    case 
of,  457 
Alimentary  tract,  effect  of  nitrous  oxid 

on,  132 
Allen,    on    "methylated    chloroform," 
874 


INDEX 


899 


Allen,  on  methylated  ether,  861 

Allis  ether  inhaler,  216 

Allocain,   692 

Allopathy  and  homeopathy,  678 

"  Alpha-eucain, "  751-753 

Alphachloralose,    723 

Alvatunder,  692 

Alypin,  540,  691-696 
action  and  uses  of,  693 
dosage  for,  693 
formation  of,  692,  693 
in  spinal  analgesia,  563,  585,  599 

Alypin-Gleitmittel,  696 

Alypin  nitrate,   696 

Alypin-Tabletten,   696 

Alypinoids,  696 

American  Painless  Dentists'  Anes- 
thetic, 696 

American  statistics  on  anesthesia,  843, 
853-856 

Amidin.      See    Holocain    hydrochlorid 

Amido-oxybenzoic  acid  methyl  ester, 
772 

Aminobenzoic  acid  ethyl  ester.  See 
Auesthesin 

Aminobenzoic  acid  isobutyl  ester.  See 
Cycloform 

^minobenzoyldiethylaminoethanolum  hy- 
droehloricum.     See  Novocain 

Aminocinnamic  acid  alkamine  esters, 
697 

Ammonia  administration  in  respiratory 
failure,  396 
with  chloroform,  287 

Ammonium  hydroxid,  in  testing  chloro- 
form, 890 

Ampules  solution  atoxyl,  10  per  cent, 
with  novocain,  1  per  cent., 
697 

Amputation   of   arm  under   local   anes- 
thesia, 506,  507 
of   breast   under   colonic   ether   anes- 
thesia, 454 
of  foot  under  spinal   analgesia,  578, 

625 
under  intravenous  anesthesia,  492 

Amydricain,  697 

Amyl  in  chloroform,  285 

Amyl  alcohol,  impurities  in  ethyl  chlorid 
due  to,  253 

Amyl  chlorid,  697,  698,  718 

Amyl  hydrid,  748,  767,  802 

Amyl  nitrate,  698 

as  an   antidote   to   cocain   poisoning, 

479 
in  respiratory  failure,  395 
use  of,  in  anemia  of   the  brain  due 
to  cocain,  539 

Amyl  salicylates  as  preservative  of 
chloroform,  292 

Amylene,  698,  699 

Snow's  first  administration  of,  23 

Amylenechloral,   699 

Amylocain,  699 

Aneesthesin  bormelin,  702 

Ansesthesin  solubile,  702 


Ana;sthesinum  solubile,  829.     See  Sub- 

cutin 
Ansesthesinum      sulfophenylicum.        See 

Subcutin 
Anspsthetica   Tabletten,    702 
Anajstheticum,    702 
AnEestheticum   Bottwini,  702 
Ana3stheticum  Witte,  702 
Anapsthin    and    anassthol,    702 
Anffisthol,    702-710 
Ansesthol   Katz,    702 
Ansesthyl,  710 
Anajsthyle.      See    Anagsthol 
Ansestiform,    710 
Anajzol,   710 
Analgos,  710 
Andolin,  710 
Andrews,   E.,  nitrous  oxid  and  oxygen 

mixture  by,  24 
Anelectrotonus,  51 

Anemia,    choice   of   anesthetic   in,    328, 
329 
of  the  brain,  due  to  cocain,  539 
due  to  electric  shock,  637 
in   sequestration  anesthesia,   469 
sequestration    anesthesia    contra-indi- 
cated in,  470 
surgical  shock  and,  384 
Anemic    subjects,    ethyl    chlorid    anes- 
thesia in,  268 
gastro-enterostomy  in,  356 
Anemogenol,  699 
Anemorenin,  699 
Anesin,  711,   724 
Aneson.     See  Anesin 
Anesthaine,   711 
' '  Anesthesia  dolorosa, ' '  479 
Anesthesin,  699-702 

Anesthesin   sulphophate.     See  Subcutin 
Anesthesine    in    spinal    analgesia,    563, 

599 
Anesthetics,   antagonism   between   salts 
and,  55 
combination  of  oxygen  with,  80-89 
effect  of  moisture  on,  76-80 
effect  of,   on  circulatory   system,  57- 
59 
on  glandular  system,  60,  61 
on  muscular  system,  59,  60 
on  nervous  system,  61,  62 
on  respiratory  system,  56,  57 
intra-abdominal      administration      of 
oxygen   in   connection   with,    89- 
91 
list  of,  688-840 
rebreathing     in     administration     of, 

100-116 
use  of  carbon  dioxid  with,  96-99 
use  of  oil  of  bitter  orange  peel  pre- 
ceding administration  of,  91-96 
warming,  63-76 
Anesthetist,  duties  of,  361,  362 

kit  of,  362,  363 
Anesthetist,  laws  relating  to,  686,  687 
liability  of,  684 
medico-legal  status  of,  675-687 


900 


INDEX 


Anesthetist,  qualifications  of,  675 
Anesthia.     See  Anesthsesin 
Anesthol,   208,  276-278,   702,   711.     See 
also  AniBsthol 
chloroform  and,  857 
in  operations  for  cleft  palate,  340 
statistics  for,  843,  848,  855,  857 
use  of,  in  children,  328 
in  heart  disease,  329 
Anesthol-chloroform,  statistics  for,  843, 

855,  857 
Anesthol-ether-chlorof orm,  statistics  for, 

843,  855 
Anesthol-ether    sequence    by    the    drop 
method,  208,  209 
for    patients     between     19     and    50, 

Statistics  for,  843,  847,  855,  857 

Anesthol-nitrous  oxid,  statistics  for, 
856 

Anesthol-oxygen,  safety  of,  325 
statistics  for,  843,  856 

Anesthone-Creme,    711 

Anesthone-tape,  711 

Anesthyl,  537 

Anestile,  537,  711 

Anestol,   711 

Anestyle.     See  Ansesthol 

Anestyle-bengue.     See  Anestile 

Aneurysm,     chloroform    indicated    for, 
310 
ether  contra-indicated  in,  248 

Angina,  dysphagin  in  treatment  of, 
735 

Angina  Ludovici,  anesthesia  in,  353, 
354 

Angina  pectoris,  nitrous  oxid  and  oxy- 
gen in  treatment  of,  670 

Angiomata  of  abdominal  wall,  opera- 
tion on,  under  spinal  analgesia, 
625 

Anhydroglucochloral,  723 

Anoci-association,  370,  388,  405,  463 
operations  under,  406,   407 

Anodyne.     See  Ethyl  chlorid 

Anodynone,  250.  See  also  Ethyl 
chlorid 

Anorectal  surgery,  eucain  lactate  in, 
758 

Anschiitz  salicylid  chloroform,  877 

Antemesin,  711 

Anterior  teeth,  technique  of  periosteal 
injection  of  anesthetic  solution 
about,  545 

Anthrax,  aeoin  in,  690 

Antidolorin,  250,  537,  712.  See  also 
Ethyl  chlorid 

Antipyrin,  712 

Antivom,  712 

Antrum  of  Highmore  operations,  an- 
esthesia in,  340 

Anus,  anesthetization  of,  514-516 
effect  of  shock  on,  386 
site  of  spinal  puncture  for,  610 

Apinol,  712 


Apnea  in  anesthesia,  57,  298,  308,  380, 

408,  409 
Apoplexy,   electric   analgesia   contra-in- 
dicated in,  635 
Apotheker    Maier  's    Radikal-Anastheti- 
kum.        See      Radikal-Anastheti- 
kum 
Apparent    death,    electric    resuscitation 

in,  636-643 
Appendectomy,  shock  in,  412 

under  colonic  ether  anesthesia,  454 
under  local  anesthesia,  518,  521 
under  spinal  analgesia,  580,  581,  589 
Appendicostomy,     open,     colonic    ether 
anesthesia     contra-indicated     in, 
457 
Aran's    anesthetic    ether.      See    .^ther 

Anaestheticus  Aranii 
Aran's  ether,  691,  750 
Arm    amputations    under    local    anes- 
thesia, 506-  507 
Arnold's  dental  anodyne,  713 
Arnott,  iga  packs  advocated  by,  537 
Aromatic  spirits  of  ammonia  in  chloro- 
form administration,  313,   316 
Arsenic  trioxid,  759 

d  'Arsonval,  anesthetic  property  of  high- 
frequency     currents      discovered 
by,  628 
Arterial  anesthesia,  492,  493 
Arterial   injection   in   local   anesthesia, 

478 
Arterioles,    effect   of   ethyl   chlorid   on, 

259 
Arteriosclerosis,      sequestration      anes- 
thesia  contra-indicated  in,  470 
Artificial  respiration,  83,  86,  463 
apparatus  for  induction  of,  396 
by  insufflation  of  pure  air  or  air  and 

oxygen,  432 
following  use  of  cocain,  539 
in  ethyl  chlorid  anesthesia,  267 
in  oil-ether  colonic  anesthesia,  462 
in  status  lymphaticus,  334 
in  treatment  of  acapnia,  409 
in  treatment  of  shock,  393-403 
by  Draeger's  pulmotor,  396-399 
by  Lewis  "pendulum  swing,"  393- 

396 
by  lung  motor,  399 
by  manual  means,  393 
by  Meltzer's  apparatus,  399-401 
Asphyxia  and  shock,  388 

death  due  to,  in  ethyl  chlorid  anes- 
thesia, 261 
in  nitrous  oxid  anesthesia,   844 
in  status  lymphaticus,   333 
due   to   nitrous   oxid,    127,    132,   134, 
136,   137,   154 
symptoms  of,   137 
due  to  nitrous  oxid  and  oxygen,  845 
in  ether  anesthesia,  189 
prevention    of,    in    ethyl   chlorid-oxy- 

gen  anesthesia,  278 
symptoms      of,      during     anesthesia, 
363 


INDEX 


901 


Asphyxiation   of   tissues   in   anesthesia, 

49 
Asphyxiation    theory    of    nitrous    oxid 

action,  124,  125 
Asthma,  anesthesia  in,  330 
chloroform  indicated  for,  310 
ether  contra-indicated  in,   248 
ether  treatment  for,  4,  176 
eupnea   in   treatment   of,   760 
spinal  analgesia  in,  cases  of,  586 
Atheroma,    ether    contra-indicated    in, 
248 
sequestration    anesthesia    contra-indi- 
cated  in,  470 
Atheromatous     conditions,     choice     of 

anesthetic  in,   328 
Athletes,     administration     of     nitrous 
oxid  in,  140 
choice  of  anesthetic  in,  329 
ethyl   chlorid   anesthesia    contra-indi- 
cated in,   269 
oil-ether  colonic  anesthesia  for,  461 
preliminary  medication  in  anesthetiz- 
ing, 371,  372 
Atoxyl  and  novocain,  818 
Atropin,  463,  464,  465,  688 

administration  of,   during  anesthesia 

in  status  lymphaticus,  334 
as   preventive    of   cardiac   inhibition, 

402 
in  acute  mania,  669 
in  preliminary  medication,  371,  373, 

461,  612 
in  respiratory  failure,  394 
in  shock  prevention,  402 
omission   of,   in  post-operative  treat- 
ment, 378 
preceding  adenoid  and   tonsil   opera- 
tions, 341 
preceding  anesthesia,  328,  329,  331 
preceding     intratracheal     anesthesia, 

427 
preceding   nitrous   oxid-oxygen   anes- 
thesia, 165 
with  ethyl  chlorid,  373 
Atropin   sulphate   in   intravenous   anes- 
thesia,  524 
Automatic     closing     tubes     for     ethyl 

chlorid,   254,  255 
Auto-observations    under    spinal    anal- 
gesia, 577,  580,  581 
Avamresco's  sites  for  spinal  puncture, 

610 
Axillary    adenitis    under    colonic    ether 

anesthesia,  454 
Axillary    glands,     enlargement    of,    in 
status  lymphaticus,  332 

Babcock  on  spinal  analgesia,  581,  583, 
595,    612 
on    cerebrospinal    fluid    diffusion    in, 

568,  569 
on  solution  for,  603 
on  technique  in,   587,   622,   623 
Babcock 's  needle  for  spinal  analgesia, 
615 


Baglioni's    theory    of    anesthesia,     46, 

47 
Bainbridge,  W.  S.,  on  spinal  analgesia 

and  spinal  anesthesia,  554-627 
Bainbridge 's    method    of    cocain    steri- 
lization, 605 
of  intra-abdominal  administration  of 

oxygen,  89,  90 
of  spinal  analgesia,  600,  604 
Bandages,   cutting   of,   preceding   anes- 
thesia,  337 
Bandaging  in  arterial  anesthesia,   492, 
493 
in  shock  prevention,  403 
in  venous  anesthesia,  490-492 
Barium  hydroxid  in  testing  purity  of 

oxygen,  895 
Barker  on  adrenalin,  478 

on    spinal    analgesia,    567,    568,    571, 
590,  591,  592,  602 
Barker's   anesthetic,   713 
Barker's  experiments,  on  cerebrospinal 
fluid  diffusion,  568 
with  stovain  injection  in  spinal  anal- 
gesia, 571,  572 
Barker's  solution   for   spinal  injection, 

568,  569,  579 
Barker's    stovain-glucose    solution    for 

spinal  analgesia,  602,  603 
Baskerville,    experiments   of,    on    effect 
of    moisture   on   anesthetics,    76, 
77 
investigations     of,     on     storage     of 

ether,  868 
on    heat    generated    by    chloroform- 
ether  mixture,  706-710 
Baskerville     and      Gwathmey,      experi- 
ments    of,     on     warming     ether 
vapor,   71-73 
Baskerville  and  Hamor,  on  decomposi- 
tion of   chloroform,   887-889 
Battelli,  experiments  of,  on  electric  re- 
suscitation,  637 
Baume,   ether   manufactured  by,   860 
Behr  on  ethyl  chlorid  anesthesia,  267 
Benesol,   713 

Bengue's  mentholdragees,  713 
Bennett's  nitrous  oxid-ether  apparatus, 

218 
Benzcain,  713 
Benzene,  284,  713,  714 
Benzenaform.         See      Carbon       tetra- 

chlorid 
Benzin,  721 

in  Schleich's  mixtures,  703,  704 
Benzineroid.      See   Carbon   tetrachlorid 
Benzinof  orm.      See     Carbon     tetra- 
chlorid 
Benzoylaminoethanol,  714 
Benzoyl  -  beta  -  hydroxy  -  tetramethyl- 

pyrrolidin,   714 
Benzoyl-ecgonin-methyl-ester,   725 
Benzoyl  -  ethyl-dimethylamino-propanol- 
hydrochlorid,      819.        See      also 
Stovain 
Benzoyl  methyl  triacetonalkamine,   715 


902 


INDEX 


Benzoyl      morphin,      715.         See     also 

Peronin 
Benzyl-morphin  hydrochlorid,  802 
Benzoyl  peroxid,  714 
Benzoyl  quinin,  715 
Benzoyl    vinyl     diacetonalkamin.      See 

-Eucain-B. 
Benzoylpseudotropein,    833.      See    also 

Tropacocain 
Benzoylpseudotropein  hydrochlorid,  832 
Benzoyl   -    triacetone   -   alkamin   -   car- 

boxyl,  714,  715 
Benzoyl-tropein,  715 
Bernard,  Claude,  on  chloroform,  26 
theory    of    anesthesia    advanced    by, 

34 
use  of  morphin  hydrochlorid  by,  779 
Bert  on  nitrous  oxid  anesthesia,  126 
Bert's  apparatus  for  nitrous  oxid  and 

oxygen,  24 
Bertel  on  chloroform  and  oxygen,  26 
Berzelius  on  chloroform,   873 

theory  of  etherification  advanced  by, 

862 

Beta  -  benzoyloxy-beta-3  :4-methylenedi- 

oxyphenyletlvyldimethylamin,  715 

Beta-  ethyletramethyldiaminoglycerin 

benzoyl  monochlorid,  715 
Beta-eucain.     See  Eucain-B. 

and  epinephrin,  statistics  for,  842 
in  spinal  analgesia,  563,  599 
Beta-eucain  hydrochlorid,  756 
Beta-eucain  lactate  in  spinal  analgesia, 

563,  599 
Beta  -  gamma  -  dibenzoyloxy  -  dimethyl- 

propylamin,   715 
Beta-isoamylene,    801,    802.     See   Amy- 

lene 
Betacain.     See  Eucain-B. 
Beven  on  acid  intoxication  due  to  anes- 
thetics, 414 
Biberfield,   experiments   of,   vvfith   novo- 

cain-adrenalin,  540 
Bicarbonate   of    potash   in   preliminary 

treatment  of  kidneys,  364 
Bichlorid    of    ethidene    introduced    by 

Clover,  25 
"Bichlorid    of    methylene,"    introduc- 
tion of,  24 
Bichlorid  solution  dish,  615 
Bier  on  spinal  analgesia,  559,  560,  562, 
563,  567,  568,  602 
method  of,  755 
Bier's  method  of  local  anesthesia,  490- 
492 
arterial  injection  in,  478 
in  hernia,  521 
.  limitations  in  use  of,  586 
stovain  solution  for,  602 
tropacocain  solution  for,  601 
of  thyroid  surgery,  503,  504 
of  venous   anesthesia,  490-492 
Bigelow,  Jacob,  on  Morton,  14 
rhioglene  introduced  by,  808 
Billroth 's  mixture,  689 
Billroth  's  mixture  A.  C.  E.,  715 


Biltz  on  chloroform  Pictet,  880,  881 
Binz's  theory  of  anesthesia,  34 
Bitter  orange  peel.     See  Oil  of  bitter 

orange  peel 
Bivalent  carbon  hypothesis,  42,  43 
Black  bear's  foot,  764 
Bladder,  anesthesia  of,  with  antipyrin, 
712 
care    of,    preliminary    to    anesthesia, 

364 
local  anesthesia  of,  512,  513 
Blake  cone,  102 
Bleaching    powder,    in    preparation    of 

chloroform,   873 
Bloch  on  the  effects  of  ether  upon  the 

_  blood,  187 
Blocking  the   cervical  plexus  in   goiter 
operation,  503 
in  surgery  of  neck,  501 
line   of   stitches,    dosage  for,   406 
Blood,  action  of  chloroform  upon,  298- 
301 
effect  of  anestheti'?s  on,  57-59 
effect  of  ether  upo.n,  185-188 
effect  of  nitrous  oxid  on,  128-130 
in    stools   under    colonic    ether   anes- 
thesia, 455 
Blood     changes    in    intravenous    anes- 
thesia, 533,  534 
Blood    pressure    and    shock,    383,    384, 
410-413 
during    oil-ether    colonic    anesthesia, 

463 
effect  of  abdominal  pressure  on,  401 
effect  of  anesthetics  on,  59 
effect  of  ethyl  chlorid  on,  259,  260 
effect  of  nitrous  oxid  on,  130,  131 
in  chloroform-oxygen  narcosis,  87 
in  ether-oxygen  narcosis,  87 
in  intravenous  anesthesia,  533,  534 
in     nitrous     oxid-oxygen     anesthesia, 

166,    167 
in   operations   under   Crile  's   method, 

402,  403 
in  spinal  analgesia,  581,  595 
increase  of,  in  shock  prevention,  402- 

404 
relation    of,    to    respiration    in   ethyl 
chlorid  anesthesia,  259 
Blood-pressure  apparatus  of  McKeson, 

409,  411 
Bloodless  field   for   adenoid   and  tonsil 

operations,  344,  345 
' '  Bloodless ' '    operations    with    electric 

analgesia,  634 
Blue  light,  as  an  anesthetic,  715 
Blumdell,     ice     packs     advocated     by, 

537 
Bodine's  tubes  of  cocain  solution,  482 
Body   weight,   loss   of,   following   ethyl 

chlorid  anesthesia,  265 
Bonain,   715 

Bonawische  mixture.     See  Bonain 
Bone   resection  under   local  anesthesia, 

512 
Boothby,  on  warmed  ether  vapor,  73-75 


INDEX 


903 


Boothby  and  Cotton  apparatus  for  ni- 
trous     oxid-oxygen      anesthesia, 
160-170 
Boothby    and    Cotton    face    mask    for 
nitrous    oxid-oxygen    anesthesia, 
166 
Boro-chloretone,  716 
Borsain,  716 
Bottger,     preparation     of     chloroform 

from  acetone  by,  874 
Boullay,  manufacture  of  ether  by,  860 
Boyle     on     ethyl     chlorid     anesthesia, 

267 
Brain,    effect    of    anoci-association    on, 
370 
effect  of  chloroform  on,  301 
effect  of  shock  on,  384 
examination    of,    under    local    anes- 
thesia, 496 
Brain  cell  changes  under  nitrous  oxid 

anesthesia,  404,  405 
Brain  cell  exhaustion  under  ether  anes- 
thesia, 404,  405 
Brain  surgery,  anesthesia  in,  354 
chloroform  indicated  for,   310 
sequestration  anesthesia  indicated  in, 
469,  470 
Bramwell,  on  advantages  of  hypnotism 
in  anesthesia,  647 
method    of    inducing    hypnosis    em- 
ployed by,  657 
Brandwundenol,  716 
Braun,  experiments  of,  with  novocain- 
adrenalin,   540 
formulas    of,    for    cocain    solutions, 

481,  482,  489 
on  adrenalin,  478 
on  eucain-B,  755,  756 
on  layer  infiltration,  503 
on  local  anesthesia  in  hernia,  521 
Braun 's    inhaler    for    chloroform-ether 

administration,  323 
Braun 's   method   for  circumcision,   514 
for   thyroid   operations,   503 
in  local  anesthesia  of  skin,  495,  496 
Braun 's  novocain-suprarenalin   solution 

for  spinal  analgesia,  603,  604 
Braun 's  solutions  for  anesthesia,  716 
Braun 's  suprarenin  tablets,  716 
Breast,   amputations   of,   under   colonic 
ether   anesthesia,  454 
carcinoma  of,  under  oil-ether  colonic 
anesthesia,  465 
Breast  surgery  under  local  anesthesia, 

505,  506 
Breathing.     See  Eespiration 
Brenz     eatechin     methyl-benzyl     ether. 

See  Brenzcain 
Brenzcain,  716 
British     Pharmacopoeia,     ethyl    chlorid 

tests  prescribed  by,  257 
Bromaform,  717 

and  ethyl  bromid,  853 
Bromal,  717 

Bromic  ether,  738-748.     See  also  Ethyl 
bromid 


Bromids     in     preliminary     medication, 
329,  371,  653 
for  spinal  analgesia,  612 
Bronchi,  effect  of  nitrous  oxid  on,  128 
Bronchitis,  anesthesia  in,  330 
chronic,  spinal  analgesia  in,  586 
ether  contra-indicatnd  in,  342 
post-anesthetic,  caused  by  ether,   189 
Brown  on  decomposition  of  chlorofo"rm, 

885,  886 
Brucin,  717 

Briining  on  effect  of  moisture  contents 
of  air  on  lungs,  78-80 
on   value   of    oxygen   with   narcotics, 
83,   86 
Brunn   on    mode   of   action   of   nitrous 

oxid,  126 
Brunton,  Lauder,  on  chloroform,  26 
Briistlein  on  pantopon,   799 
Biinte  and  Moral's  local  anesthetic,  717 
Burckhardt   on   intravenous   anesthesia, 

524 
Biirker's  theory   of   anesthesia,   48 
Busse  on  spinal  analgesia,  595 
Butyl     alcohol,      impurities     in     ethyl 
chlorid  due  to,  253 
in  chloroform,  285 
Butyl-chloral  hydrate,  718 
Butyl  chlorid,   718 
Butyl  hydrid,   718 
Butylene,  689 

Buxton  on  effect  of  nitrous  oxid  on  the 
blood,  128 
on  ethyl  chlorid  anesthesia,  260 
on  limitations  in  use  of  spinal  anal- 
gesia,  586 
on  rectal  etherization,  435 
Buxton 's  apparatus  for  ether  adminia- 

tration  per  rectum,  441 
Byasson  on  formic  ether,  748 

Cachexia,   intratracheal   insufflation   in, 
432 

Cactin,  hyoscin,  and  morphin,  768 

Cadet  on  ether,  860 

Caglieri  on  spinal  analgesia,   560,  561, 
562,  565,  566 

Calcium  chlorid,  chloroform  dried  over, 
878,  879 

Calcium      guaiacol      sulphonate.        See 
Guaiacyl 

Calculi,    renal    or    biliary,    passage    of, 
anesthetic  treatment  for,  667 

Camphor  phenylated,  718 

Camphorated  oil  administration  in  res- 
piratory failure,  396 

Camphorated  salol.     See  Salol  camphor 

Canadol,  718 

Cancer,  anesthesia  in,  330 

Canestro,    use    of    magnesium    sulphate 
by,  771 

Cannula   for  Bier's  venous  anesthesia, 
491 
for  spinal  analgesia,  614,  615 
introduction  of,  in  intravenous  anes- 
thesia, 527 


904 


INDEX 


Cantelupe,   on   action   of  ethyl  chlorid, 

261 
Caprylic  hydrid,  718 
Carbamidum,  805 
Carbolic  acid,  718,  719 
Carbon  dioxid,   719 
early  use  of,  2 

effect  of,  in  rebreathing,  111,  112 
on  arteries  and  veins,  114 
on  intestines,  114,  115 
for  restoration  of  respiration,  463 
in   dental  anesthesia,  537 
in  oil-ether  colonic  anesthesia,  462 
loss  of,  in  shock  causation,  406-408 
physiological  role  of,  96,  97 
reduction  of,  in  the  blood  by  chloro- 
form, 298 
causes  of,  97,  98 
effects  following,  97 
use  of,  with  anesthetics,  96-99 
Carbon  dioxid  snow,  537 
Carbon  disulphid,  719,  720 

removal  of,  from  carbon  tetrachlorid, 
883 
Carbon  monoxid,  720 
Carbon  tetrachlorid,  720,  721,  883 
preparation  of  chloroform  from,  285, 
875,  876 
Carbonyl    chlorid    as   product    of    pure 
chloroform  decomposition,  290 
in    chloroform,    286,    884,    885,  887, 
888 
Carcinoma,  acidosis  in,  415 

of    superior    maxilla,    operation    for, 
und«r  spinal  analgesia,  574 
Carcinomatous    gland    case,    results   in, 
due  to  lack  of  preliminary  medi- 
cation, 370 
Cardiac  arrest  due  to  chloroform,  386  _ 
Cardiac    cases,    use    of    rebreathing    in 

anesthetizing.   111 
Cardiac   massage   following  chloroform 
poisoning,  642 
in  ethyl  chlorid  anesthesia,  267 
in  status  lymphaticus,  334 
Cardiac  syncope  due  to  chloroform,  305, 

306 
Carlson  and  ethyl  chlorid,  27 

on    chloroform,    299 
Carotid  arteries,    compression    of,    467, 

468 
Carotid  gland,  sequestration  anesthesia 

for  removal  of,  471 
Carpophyllic  acid.     See  Eugenol 
Castor    oil    in    preliminary    treatment, 

365,  461 
Catarrh,  eugallol  in  treatment  of,  759 
formaldehyd-kelene  in   treatment   of, 

760 
of  upper  air  passages,  ether  contra- 
indicated  in,  342 
Cathartics,    use    of,    preceding   adenoid 

and  tonsil  operations,  340 
Catheters,  rubber,  for  removal  of  blood, 
in  adenoid  and  tonsil  operations, 
345 


Catheters,    tracheal,    for    intratracheal 
insufflation,  425,  426,  430 
introduction  of,  426-429 
Caustica,  721 

Cavendish,  oxygen  studied  by,  893 
"C.  E."  mixture,  81,  721 
Hewitt's,    764 
safety  of,  325 
statistics  for,  843,  855 
use  of,  in  children,  327 
in  heart  disease,  329 
with  air,  safety  of,  325 
C.  E.  mixture-ether-chloroform  sequence, 

326 
C.  E.  mixture-ether  sequence,  326 
Ceratum  odontalgicum,  721 
Cerebellar  tumor,  excision  of,  under  se- 
questration anesthesia,  469 
Cerebral  diseases,  convulsions  from,  ni- 
trous oxid-oxygen  in,   667 
Cerebrospinal   fluid,   diffusion   of,   565- 
572 
escape  of,  on  puncture,  618,  619,  621, 

622 
in  spinal  analgesic  solutions,  599,  600 
physiology  of,  563-572 
specific  gravity  of,  565 
Cerebrospinal  meningitis,  death  due  to 

status  lymphaticus  in,  335 
Cervical     laminectomy     under     colonic 

ether  anesthesia,  454 
Cesarian  section  under  spinal  analgesia, 

593 
Chancel's      theory      of      etherification, 

863 
Chaput   on   spinal   analgesia,   562,   575, 
598 
on  stovain  solution  for,  602 
Charlatanism,  hypnotism  and,  649 
Charme,  654 

Chassaignac  cocain  in,  on  spinal  anal- 
gesia, 600 
Cheeks,  operations  on,  under  local  anes- 
thesia, 497 
Chelen,     250,     722.       See     also     Ethyl 

chlorid  and  Kelene 
Chemicals  and  psychic  shock,  384 
Chemistry  of  chloroform,  281-297 
Chest  dissections,  shock  in,  402 
Chest  operations,  colonic  ether  anesthe- 
sia indicated  in,  457 
Chevanne's  local  anesthetic,  722 
Chiene    on    death    due   to    spinal   anal- 
gesia, 597,  598 
Children,      administration     of      nitrous 
oxid-oxygen  in,  143 
anesthetic  treatment  for  convulsions 

in,  667 
and  shock,  387 

ether  contra-indicated  for,  248 
hypnotism  in,  655 
importance    of   psychic    influences    in 

anesthetizing,   651 
nitrous    oxid    anesthesia    contra-indi- 
cated in,  135,  136 
oil-ether  anesthesia  for,  462,  465 


INDEX 


905 


Children,  use  of  ethyl  chlorid  anesthesia 
in,  268 
use  of  spinal  analgesia  for,  561,  588 
Chininum  bihydrochloricum,  805 
Chipman    on    the    term   ' '  anesthetist, ' ' 

676 
Chlorabutanol,  772 
Chlora3thoform,  722 
Chloral,  691,  722 
Chloral-acetone  chloroform,   722 
Chloral  chloroform,  876,  877 
Chloral-menthol,  723 
Chloral-orthoform,  723 
Chloralamid.      See   Chloralformamid 
Chloralformamid,  723 
Chloralimid,  723 
Chloralose,  723 
Chloramyl,  723 

Chloran.      See    Chloral-acetone     chloro- 
form. 
Chlorates,  preparation  of  oxygen  from, 

894 
Chlorbutane,  723 
Chlorbutanol.        See      Chloretone      and 

Methaform 
Chlorbutol.     See  Chloretone. 
Chlorethyl.     See  Ethyl  Chlorid 
Chlorethylene  chlorid.     See  Ethylene 
Chlorethylidene.    See  Ethylidene  chlorid 
Chloreton,  724 

Chloretone,  463,  464,  465,  711 
in  postoperative  treatment,  378 
in  preliminary  medication,  371 

for  oil-ether  anesthesia,  460,  461 
use  of,  preceding  adenoid  and  tonsil 
operation,  341 
Chloretone   and   morphin,    doses   of,   in 

preliminary  medication,  372 
"Chloric  ether,"  872 
Chlorid     of     lime     in    preparation     of 

chloroform,  285 
Chloriden.     See  Ethylidene   chlorid 
Chloridene,  750 

Chlorin,  action  of,  on  ethyl  iodid,  252 
as   product    of   pure    chloroform    de- 
composition, 290 
formation  of,  on  exposure  of  chloro- 
form to  air,  883-888 
in  chloroform,  286,  875 
in  preparation  of  oxygen,  894 
Chlorinated  muriatic  ether,  750 
"Chlorinated"  oils  in  chloroform,  285 
Chlorojethyl,     250.       See     also     Ethyl 

chlorid 
Chlorocarbon.     See  Carbon  tetrachlorid 
' '  Chlorocarbonic  ether, ' '  884 
Chloro-ethane,     250.      See    also    Ethyl 

chlorid 
Chloroform,  administration  of,  311-323 
ammonia  in,  287 
apnea  in,  298,  308 
by  drop  method,  311 

in  case  of  acute  mania,  669 
in  locomotor  ataxia,  667 
in  passage  of  renal  or  biliary  cal- 
culi, 667 


Chloroform,      administration      of,      in 
colonic  ether  anesthesia,  439 
Snow's  scientific,  23 
with  Braun  's  inhaler,  323 
with   Gwathmey  three-bottle  vapor 

inhaler,  323 
with  Harcourt's   inhaler,   320,   321 
with  Junker 's  apparatus,  322 
with      Eoth-Drager      oxygen      and 

chloroform    apparatus,    317-320 
with  the  Yankauer  mask,  203 
alcohol  as  preservative  of,  283,  285, 

290,  291,  295 
American,  purity  of,  891,  892 
amount    of,    used    with    Eoth-Drager 

apparatus,    319 
and  shock,  389 
as  a  solvent,  284 
as  preliminary  to   ether,   310 
atropin    as    preliminary    medicament 

to,  373 
changes  in,  due  to  combination  with 

oxygen,  294,  295 
chemistry  of,  281-297 
Clover 's  inhaler  for,  23 
combined  with  ethyl  chlorid  and  ether 

(anesthol),   276-278 
combining  oxygen  with,   80,   81 
containers  for,  292,  293,  294 
the  drop  method,  200,  201 
decomposition  of,   289-296,   290,   883, 
889 
due  to  strong  light,  295,  296 
density  of,   283 
early  prejudice  against,  23,  25 
early  use  of,  20-27 
effect  of  agitation  on,  296 
effect  of  temperature  on,  283 
effect  of  warming  on,  63,  64 
effect  of,  upon  blood  pressure,  59 
upon   the   circulatory   system,   298- 

302 
upon  the  glandular  system,  303-305 
upon  the  kidneys,  303,  304,  309 
upon  the  liver,  304 
upon  the  muscular  system,  302,  303 
upon  the  nervous  system,  302 
upon  the  respiratory  system,  298 
elimination  of,  309 
ethyl  chlorid  and,  279 
ethyl  chlorid  compared  to,  258,  259, 

260,  266,  267 
experimental  use  of,  in  animals,  335, 

336 
fatty   metamorphoses,    following    use 

of,  88 
Harcourt's  inhaler  for,  26,   320,  321 
history  of,  c.z  an  anesthetic,  281,  871- 

873 
impurities  in,  285-289 

fatal  after-effects  due  to,   286-288 
in  A.  C.  E.  mixture,  688,  689 
in  oil-ether  rectal  anesthesia,  462 
in  Schleich's  mixture,  703-705 
in  spinal  analgesia,  588 
Moore-Eoaf  theory  of  action  of,  44,  45 


906 


INDEX 


Chloroform  odor  of,  889 
organic  impurities  of,  890 
Pilling  dropper  for,  312 
preparation  of,  285,  873-876 
preservatives  of,  290,  291,  292 
pure,  decomposition  of,  289-296 
purification  of,  285,  877-883 
relative  anesthetic  value  of,  311 
residue  of,  889 
safety  of,  83 

as    affected   by   temperature,    314, 
315 
shipping  of,  296 
Simpson's  early  use  of,  20,  21 
Snow's  inhaler  for,  23 
solubility  of,  284 
special  physiology  of,   297-310 
specific  gravity  of,  283,  284,  889 
stability  of,  289 

standards  of   purity  for,  296,  297 
substitutes  for,  23,  24 
temperature  stimulus  and,  69 
uses  of,  in  medicine,  284,  285 
varieties  of,  of  European  make,  876, 

877 
verified  tests  for  purity  of,  889-891 
warmed,  314 
with  acetic  acid,  724 
with  air,  safety  of,  325 
with  alcohol,  295 
with  amyl  nitrite,  698 
with  atropin,  371,  373 
with  chloral  hydrate,  722 
with  ether,  heat  resulting  from,  706- 
710 

in  elderly  persons,  328 

in  submucous  operations,  340 

nitrous     oxid-ether     sequence     fol- 
lowed by,  325 

statistics  for,  842 
with  ethyl  chlorid,  115,  116 

dosage  for,  116 

rebreathing  in   the   administration 
of,  115,  116 
with  morphin,  26,  371 
with  nitrous  oxid  and  ether,  223,  224 
Chloroform  and  oxygen,  26,  27,  87,  294, 
295,   857 

in  adenoid  and  tonsil  cases,  342 

in  brain  operations,  354 

in  diabetes,  330 

in  dyspnea,  330 

in  elderly  people,  328 

in   goiter,   353 

in  obese  patients,  329 

in  obstetric  cases,  355 

in  respiratory  diseases,   330 

in   thyroidectomy,   353 

in  tuberculosis,  329 

safety  of,   325 

statistics  for,  843,  851,  855 
Chloroform  anesthesia,  after-effects  of, 
310,  415 

due  to  impurities,  286 
antivom  in,  712 
blood  changes  due  to,  58 


Chloroform  anesthesia,  by  intratracheal 
insufHation,  429 
contraindications  for,  310 
kidney  diseases,  330 
rectal  cases,   355 
short  operations,  338 
status  lymphaticus,  333 
death  due  to,  305,  841,  842 
excitement  during,  307 
for  patients  between  19  and  50,  328 
in  adenoid  and  tonsil  cases,  341,  342, 

343      ■ 
in  cancer,  330 
in  children,  326,  327,  328 
in  circumcision,  355 
in  curettage,  355 
in  epileptics,  331 
in  heart  diseases,  329 
in  insane  patients,  331 
in  laparotomy,  355 
in  mastoid  operations,  339 
in  obstetrics,  368 

in  operations  for  cleft  palate,  340 
in  operations  on  the  respiratory  tract, 

339 
in   peritonitis    or   intestinal    obstruc- 
tion, 356 
in  sequestration  anesthesia,  471 
in  submucous  operations,  340 
in  tracheotomy,   353 
indications  for,  310 
respiratory   difficulties  in,  380 
stages  of,  306-309 
statistics  for,  842,  843,  851,  852,  853, 

854,  855,  857 
status    lymphaticus    associated    with, 

331 
use    of    Lewis    pendulum    swing    in, 
394-396 
Chloroform  Anschiitz,  877 
Chloroform  Liebreich,  876 
Chloroform  Pictet,    289,   877,   880,   881 
Chloroform  poisoning,  413 
cases  of,  414,  415 
symptoms  of,  415 
use  of  oxygen  and,  86 
Chloroform  Schering,  876 
Chloroform    treatment    for    acute    pain 
in  tetanus,  667 
in  cases  of  puerperal  eclampsia,  667 
in  convulsive   affections,   667 
in  strychnin  poisoning,  667 
"Chloroforme  Officinal,"  880 
Chloroform-ether-chloroform      sequence, 

326 
Chloroform-ether-menthol,  725 
Chloroform-ether-nitrous  oxid  sequence, 

141,  142,  143 

Chloroform-ether-oxygen  narcosis,  87,  88 

Chloroform-ether    sequence,     207,     208, 

240,   326 

statistics  for,  843,  847,  848,  855,  857 

Chloroforming,      electric      resuscitation 

following,  638-642 
Chloroformium       albuminatum.         See 
Chloroformium  Gelatinosum 


INDEX 


907 


Chloroformium    colloidale.      See    Desal- 

gin 
Chloroformium  gelatinosum,   725 
Chloromethane.     See  Methyl  Chlorid 
Chlorosis,  sequestration  anesthesia  con- 
tra-indicated in,  470 
* '  Chloroxycarbonic     acid, ' '     formation 
of,  on  exposure  of  chloroform  to 
light,  884 
Chloryl,  725 

anesthetic,    725 
Cholecystectomy  under  spinal  analgesia, 

560 
Christison,  on  action  of  sulphuric  acid 

on  chloroform,   878 
Cinnamic      acid      as      preservative      of 

chloroform,  292 
Cinnamon,     tincture     of,     in     dietetic 

shock,  387 
Circulatory     system,     effect     of     anes- 
thetics on,  57-61 
effect  of  ether  upon,  185-188 
effect  of  ethyl  chlorid  on,  259,  260 
effect  of  nitrous  oxid  on,  128,  131 
reflex  changes  in,   in  anesthesia,  61, 
62 
Circumcision,  anesthesia  in,  355 
anesthetization  of  prepuce  in,  514 
ethyl  chlorid  anesthesia  for,   268 
separate  injection  of  frenum  in,  515 
under  complete  spinal  analgesia,  576 
under  local  anesthesia,  486,  513,  514 
under  oil-ether  colonic  anesthesia,  464 
Circumscribing  injection  in  local  anes- 
thesia, 495,  496 
Citrate   of  potash   in  preliminary   care 

■     of  kidneys,  364 
Citronellol,    as   preservative    of   chloro- 
form, 292 
Civil  liability  of  physician,  681 
Clark,  on  action   of   sulphuric   acid  on 

chloroform,   878 
Clavicle,    fractured,    wiring    of,    under 

local  anesthesia,  505,  506 
Cleft    kidney,    associated    with    status 

lymphaticus,   333 
Cleft  palate,  anesthesia  in,  340 

associated    with    status    lymphaticua, 
333 
Climate  and  anesthesia,  853,  854 
Closed   method   of   administering  ethyl 
chlorid,  273-276 
of     anesthesia,     contra-indicated     in 
elderly  people,  328 
in  obese  patients,  329 
in  status  lymphaticus,  333 
of  etherization,  Clover's,  177 

ill  effects  of,  on  the  lungs,  101,  102 
Clover,  J.  T.,  177,  749 

on  nitrous  oxid  and  ether,  25 
Clover  chloroform  inhaler,  23 
Coburn    apparatus    for    nitrous     oxid- 
oxygen  anesthesia,  149,   150,  151 
Cocadrenal,   725 
Cocasthylin   725 


Cocain,  370,  483,  691,  692,  725,  726 
and  epinephrin,  statistics  for,  842 
and     ethyl     chlorid,     statistics      for, 

842 
as   preventive   of   cardiac    inhibition, 

402 
discovery  of,  555,  556 
experimentation  with,   555-559 
in  anesthesia  of  scalp,  497 
in    spinal    analgesia,    576,    585,    600, 

601,  604,  624 
in  tonsillectomy,  500 
in  treatment  for  sneezing,  387 
in  treatment  of  nose,  499,  500 
injection  of,  preliminary  to  puncture 

in  spinal  analgesia,  618 
introduction   of,   in   local   anesthesia, 

478 
poisonous  action  of,  478,  479 
statistics  for,  842 
sterilization  of,  Bainbridge  's  method 

of,  605 
substitutes   for,   in   local    anesthesia, 

478 
toxicity  of,  600,  601 
use  of,  in  dentistry,  538-543 
precautions  in,  539 
preparation    of    solutions   of,    539, 

540 
sterilization  of  solutions  of,  540 
substitutes  for,  540-542 
Cocain  arabinate,  726 
Cocain  benzoate,  726 
Cocain  "block"  in  operations  upon  ex- 
tremities, 402 
Cocain  borate,  726 
Cocain  carbolate,  726 
Cocain  formate,  726 
Cocain  hydriodid,   726 
Cocain  hydrobromid,  726 
Cocain  hydrochlorid,  726 
Cocain      hydrochlorid      solution      with 

methaform,  773 
Cocain    infiltration,     in     general-    anes- 
thesia, 485 
in  venous  anesthesia,  491 
Cocain  lactate,  726 
Cocain  nitrate,  726 
Cocain  oleate,  726 
Cocain  phenate,  726 
Cocain  phenylate,  726, 
Cocain    solutions,    Bodine's    tubes    for, 
482 
Braun  formulas  for,  480,  481 
for  surface  anesthesia,  489 
preparation  of,  479,  480 
sterilization  of,  480-482 
syringes  and  bottles  for,  48*1 
Cocain  spray,  727 
Cocain  tartrate,  727 
Cocain-adrenalin  anesthesia,  operations 

under,  485 
Cocain-adrenalin  ointment,  726 
Cocain-adrenalin      solution      for      skin 
wheal  production,  494 


908 


INDEX 


Cocain-adrenalin  solution  in  anesthetiza- 
tion of  urethra  and  bladder,  512 
in  circumcision,   513 

Cocain-aluminum  citrate,   726 

Cocain-ethyl  chlorid,   726 

Cocainization     of     larynx     for     intra- 
tracheal insufflation,  427 

Cocainol,  699,  727 

Cocainol  bismuth  tablets,  727 

Cocainol  condurango  tai)lets,  727 

Cocainol  quinin  tablets,  727 

Cocainol  sanoform  dusting  powder,  727 

Cocainolbalsam,    Schmerzstillender,    727 

Cocainol-creme,  727 

Cocainol-Losungen,  728 

Cocainol-menthol  drops,  727 

Cocainum   arabinicum,   728 

Cocainum      phenylicum      Merck-Oefele, 
727 

Cocainum  phenylicum  poinsot,  727 

Cocainum  phenylicum  vian,  727 

Cocain-urethane,    727 

Co-capsulin,   728 

Codrenin,  728 

"Coin"    freezing    with    ethyl    chlorid, 
670 

Cold  as  local  anesthetic,  477,  537,  728- 
730 

Cold  perspiration  in  anesthesia,   60 

Colic,  biliary,  anesthetic  treatment   in, 
666 
renal,  anesthetic  treatment  in,  666 

Collapse    during    anesthol    administra- 
tion, 277 
following    ethyl    chlorid    anesthesia, 
265,  272 

Collins'  technique  in  preliminary  medi- 
cation,  372 

Collodion,  bottle  for,  615 

Colloidal  chloroform,  732 

Cologne,  use  of,  in  adenoid  and  tonsil 
operations,  342 

Colombani    on    tropacocain    in    spinal 
analgesia,  601 

Colon,  distention  of,  in  oil-ether  colonic 
anesthesia,  462 

Colonic  absorption  of  ether,  anesthesia 
by,  433-458 

Color  reflex  in  administration  of  chloro- 
form, 315,  316 

Colton,  G.  Q.,  10,  24 

use  of  nitrous  oxid  in  dentistry  by, 
118,  119 

Combination    and    sequences    in    anes- 
thetics, list  of,  325,  326 

Combined  oxygen  narcosis,  87,  88 

Comfort    of    patient    during    operation 
under  local  anesthesia,  486-488 

"Compound  anesthetic  ether,"  730 

defined,  178 
Compressed   lozenges  orthoform,   730 

Compressed  tablets  anesthesin,  730 
Compression   of   nerve   trunks   in   local 

anesthesia,   476 
Conductive  anesthesia,  536 

by  perineural  injection,  548-552 


Conephrin,  730 

Coniferin  as  preservative  of  chloro- 
form, 292 

Conjunctival    reflexes,    absence    of,    in 
ethyl  chlorid  anesthesia,  263 
in  chloroform  administration,  316 

Connell   on  endopharyngeal  anesthesia, 
235,  238,  239 
on   ether  vapor  concentration,  241 

Connell  method  of  nitrous  oxid-oxygen 
anesthesia,  endopharyngeally, 
159,  160 

Connell 's  anesthetometer,  160 

Connell 's  breathing  tube,  392 

Consciousness  during  spinal  analgesia, 
578 

Contact  anesthesia.  See  Pressure  anes- 
thesia 

Containers  for  chloroform,  292,  293 
for  ether,  869 
for  ethyl  chlorid,  254-256 
glass  vs.  metal,  255,  256 

Convulsions  due  to  aromatic  hydrocar- 
bons, 689 
effect  of  warming  the  anesthetic  on, 
65 

Convulsive  affections,  anesthetic  treat- 
ment for,  667 

Copper  oxid  in  testing  purity  of  oxy- 
gen, 895 

Cordus,  Valerius,  ether  prepared  by, 
858 

Cork  stoppers  for  chloroform  contain- 
ers, objections  to,  294 

Corneal  reflexes,  absence  of,  in  ethyl 
chlorid  anesthesia,  263 

Corning,   discovery  of   spinal   analgesia 
by,  556,  557,  558,  562,  563 
on  cocain,  478 

sequestration    method   used   by,    467, 
468 

Corona,   730,  731 

Cortical  neurons,  effect  of  anesthesia 
on,  41 

Coryl,  537.     See  also  Chloryl 

Coryloform,  731 

Coughing,  during  anesthesia,  381,  450 
during  intratracheal  anesthesia,  429 

Coughlin's  ether  rausch,  209-211 

Cotton-Boothby  apparatus  for  nitrous 
oxid  -  oxygen  anesthesia,  160- 
170 

Cotton-Boothby  introducing  cannula, 
Ehrenf ried  's  modification  of,  for 
soft  rubber  tubes,  426 

Coumarin,  731 

Craniotomy,    bilateral    suboccipital,    in- 
tratracheal insufflation  indicated 
in,  431 
under  colonic  ether  anesthesia,  454 
under  spinal  analgesia,  587 

Creme  Dehne,   731 

Creosote,  718,  731 

Crile     on      anoci-association,     367-370, 
388,  405,  463 
on  cerebrospinal   fluid  diffusion,  566 


INDEX 


909 


Crile   on   combination  of  general   with 

local  anesthesia,  27,  485 

on  lumbar  puncture,  558 

on    necessity   of    preliminary   mental 

preparation,   366,   367,    369,   370 

on  prevention  of  shock,  385,  402-406 

Crile    method    for    gastro-enterostomy, 
356 
in  goiter,  353,  354 
of  resuscitation,  642 

Crile 's  abdominal  hysterectomy  chart, 
405 

Crile 's  case  of  death  in  nitrous  oxid 
and  oxygen  anesthesia,  846 

Crile 's  chart  of  mortality  rate  of  op- 
erations under  anoci-association, 
406 

Crile 's  pneumatic  rubber  suit,  404 

Crile 's  theory  of  de-oxygenation,  as 
cause  of  shock,  401.  See  also 
Vasomotor    paralysis 

Crile 's   thyroidectomy   chart,   406 

Grim  on  medico-legal  status  of  anes- 
thetist,  675-687 

Criminal  liability  of  physician,  685 

Criminal  negligence,  686 

Criminals  and  resistance  to  surgical 
shock,  384 

Crombil  on  medication  before  anesthe- 
sia, 26 
on  morphin  and  chloroform,   26 

Cross  and  Spilsbury,  on  purity  of 
chloroform,    882 

Cuneo    on  ether   disinfection,   673,    674 

Cunningham,  experiments  of,  on  elec- 
tric resuscitation,   637 

Cunningham  apparatus  for  colonic 
ether   anesthesia,   441,   444 

Curettage,   anesthesia   for,   355 

Cushing  on  local  anesthesia,  493,  519 

Cushing's  anesthetization  for  inguinal 
hernia,   519-522 

Cushing's  sketch  of  nerves  in  inguinal 
hernia  operations,  521 

Custer,  on  use  of  sal  anaesthicum 
Schleiehii,    809 

Cyanosis,  avoidance  of,  in  nitrous  oxid- 
oxygen  anesthesia,  167 
during  intratracheal  insufflation,  429 
in  asphyxia  with  ethyl  chlorid,  261 
in  ethyl  chlorid  anesthesia,  263,  272, 

275 
in  nitrous  oxid  anesthesia,  138,  134, 
168 

Cycloform,   731,  732 

Cyclorenal,   732 

Cyst,  subcortical,  removal  of,  under 
local  anesthesia,  497 

Cystitis,  use  of  guaiasanol  in,  763 

Cystotomy,  suprapubic,  under  local 
anesthesia,  513 

Da  Costa  on   Long,   8,   10 
Dammersehlaf,    814 

Dastre,  statistics  of,  on  chloroform 
anesthesia,   853 


Davis  apparatus  for  ethyl  chlorid-ether 
by  drop  method,  223 
for    gas-ether    by    the    drop    niethod, 
223 
Davis  dropper  for  insertion  in  original 

container,   206 
Davis  heater  for  gas  or  oxygen,  223 
with      the      Gwathmey      three-bottle 
vapor    inhaler,    224 
Davis    inhaler    for    ethyl    chlorid-ether 
sequence     by     the     closed     drop 
method,  222,  275 
for  gas-ether  sequence,  221 
Davis  method  of  ether   administration, 
205,   206 
of  nitrous  oxid  anesthesia,  151 
Davis    nitrous    oxid-oxygen    apparatus, 

145-148 
Davy,   Sir   Humphry,    on   nitrous   oxid, 
4,   5,    118,    123 
oxygen  studied  by,   893 
Dawbarn's     method     of     sequestration 

anesthesia,  468,  469 
Death  due  to  acidosis,  415 
due  to   amylene,  698 
due  to  chloral  and  ether,  722 
due  to  ether,  415 

due   to   lack   of   preliminary   medica- 
tion, 370 
due  to  shock,  384 

in  cases  under  anoci-association,  406 
under     chloroform     anesthesia,     282, 

287,  305,  414,  841,  842 
under   colonic   ether   anesthesia,   437, 

455,   456 
under  ethyl  chlorid  anesthesia,  415 

causes  of,  261,  262 
under  intravenous  anesthesia,  524 
under  spinal  analgesia,  589,  596-598, 
625 
Debility,   extreme,   spinal  analgesia  in, 

587 
Decomposition    of    chloroform,    883-889 
due  to  tin  containers,  293 
upon  exposure  to  gas  light  or  naked 
flames,  295,  296 
Decomposition  of  pure  chloroform,  289- 
296 
products  of,   290 
Deep      breathing      and      concentration, 

653 
Deep  sleep,  hypnotic,  654 
Defecation,   involuntary,   following   use 

of  nitrous  oxid,  132 
"Dehydrated  ether,"  197 
Dehydration    of    protoplasm    by    anes- 
thetics,  34 
Deimann,   preparation   of   nitrous   oxid 

gas  by,  118 
Delageniere  's   method   of   sequestration 

anesthesia,  472 
Delhaye  on  magnesium  salts,  771 
Denatured  alcohol,  methyl  chlorid  pro- 
duced  from,   252,   253 
Dental  hypodermic   needles,   543 
Dental  hypodermic   syringe,   542 


910 


INDEX 


Dental  operations  under   colonic  etlier 

anesthesia,  435 
Dental   prop,   use   of,   in   ethyl   chlorid 

anesthesia,   262 
Dentalou,  732 
Dentesthin,   732 

Dentistry,    chloroform    contra-indicated 
in,   338- 
ethyl  chlorid  anesthesia  in,  268,  338 
local   anesthesia   in,   by   cocain,    538- 
543 
by  cold,  537 

by  ethyl  chlorid,  537,  538 
by  hypodermic  method,  536,  537 
history  of,   535,   536 
technique   of  injection,  543-553 
nitrous  oxid  in,  118,  119,  338 
nitrous     oxid-oxygen     anesthesia    in, 
173 
Dentists  as  anesthetists,  676 
Dentola,   732 
Dentorol,  732 

Deoxygenation  as  cause  of  shock,  401. 
See  also  Vasomotor  paralysis 
of  blood,  an  effect  of  chloroform,  299 
Deoxygenation  theory  of  anesthesia,  46 

of  nitrous  oxid  action,  124,  125 
Dermatitis  due  to  orthoform,  788 
Desalgin,  732 

Desguin    on    miagnesium    sulphate,    771 
Deutsches     Arzneibuch,     ethyl     chlorid 

tests   prescribed   by,   257,    258 
Dextrin    in   spinal   analgesic    solutions, 

599 
Dextrin-stovain      solution     for      spinal 

analgesia,   603 
Diabetes,  acidosis  in,  415 

anesthesia   in,   330 
Diagnosis,  use  of  anesthetics  in,  667 
Dialkylaminoalkyl,    3:4 — diaminobenzo- 

ates,  732 
Diaphragm,  effect  of  ethyl  chlorid  on, 
258 
effect  of  shock  on,  385 
position   of,  as  it  effects  anesthesia, 
59 
Diarrhea  following  ethyl  chlorid  anes- 
thesia, 265 
in  cases  under  colonic  ether  anesthe- 
sia, 435,  436 
Dichlorinated    chlorid    of    methyl,    281. 

See  also  Chloroform 
Dichlormethane,  777.     See  also  Methy- 
lene chlorid 
Dichloropropane,   733 
Diet  in  acid  intoxication,  413,  414 
post-operative,   379 
preliminary   to    anesthesia,    365,    366 
Dietetic  shock,  387 
Diethyl  ether,  178 
Diethyl  ketone,  804 
Diethylaminaethyl  benzoate,  733 
Diffusion  of  cerebrospinal  fluid,  experi- 
ments on,  565-572 
Digestive  tract,  effect  of  shock  on,  385 
Digitalin   in   spinal   analgesia,   585 


Dilatation   of   cardiac   muscles   due   to 
chloroform,  300 
of  pupils  in  ethyl  chlorid  anesthesia, 
261,    263,   274 
Dimethyl   ether,   776  . 
Dimethylacetal,    733 
Dimethylcarbinol  chloroform,   772 
Dimethylketal,  689 

Dimethylketone,  689.     See  also  Acetone 
Dimethyloxyguinizin.      See    Antipyrin 
Dioform,    733 
Dionin,    733,    734 

o-Dioxyphenylethanolmethylamin,  830 
Di-para-anisyl  -  monophenetyl  -  guanidin 

hydrochlorid.     See  Aeoin 
Dipropesin,   734 
Displacement    currents,    production    of 

anesthesia  by,  629,  635,  636 
Distribution     coefficient     and     narcotic 

effect,  38,  39 
Dizziness  following  use  of  ethyl  chlorid, 

338 
Doleris  on  spinal  analgesia,  560,  593 
Dolonephran,  696,   734 
Dolorant  tablets,  734 
Dolorifuge,   735 
Donitz   on    spinal   analgesia,   567,   568, 

576 
Dontocerat.      See    Ceratum    odontalgi- 

cum 
Dott    on    action    of    sulphuric   acid   on 
chloroform,   878 
on  decomposition  of  chloroform,  887 
on  impurities  in  commercial  acetone, 

882 
on   preparation   of    chloroform   from 
acetone,  874 
Double-end  ethyl  chlorid  tube,  254 
Draeger  's    pulmotor    for    artificial   res- 
piration, 396-399 
Drainage   cases,   care  of,   during   anes- 
thesia,  375 
Dreser  on  effect  of  ether  vapor  on  the 
lungs,   101,  103,  105 
on  ether  vapor  concentration,  240 
Drop  method  of  chloroform  administra- 
tion, 311-317 
dropper  for  use  in,  312 
induction    of    anesthesia    by,    312, 

313 
preparation  of  patient  for,  312 
reflexes  in,  315,  316 
warmed  chloroform  in,  314,  315 
of   ether   administration,  as  antidote 
to    drugs    used    in    spinal    anal- 
gesia, 598 
in  case  of  acute  mania,  669 
in  locomotor  ataxia,   667 
in  passage  of  renal  or  biliary  cal- 
culi,  667 
Dropper,  ethyl  chlorid,   256 

Pilling  chloroform,  312 
Droppers    for    open    method    of    ether 

administration,   199-202 
Drowning,    insufilation    of    pure    air    or 
air  and  oxygen  in,  432 


INDEX 


911 


Drowsiness,  hypnotic,  654 

Drug  habitues,  choice  of  anesthetic  in, 
329 

' '  Dry  spine, ' '  effect  of,  on  spinal  anal- 
gesia, 585,  596,  621,  625 

DuBois-Eeymond,    on    chloroform    Pic- 
tet,  881 
on  imjiure  chloroform,  288,  290 

Dubois'  theory  of  anesthesia,  34,  35 

Dumas,    formula    of    chloroform    deter- 
mined by,  872,  873 

Duration  of   operation   and   shock,  386 

Dutch   liquid,   749.     See   also  Ethylene 
chlorid 

Dyspepsia,  nervous,  antivom  in,   712 

Dysphagin,  735 

Dyspnea,  anesthesia  in,  330,  380 

following   overdose    of    nitrous   oxid, 
134 

Ear   operations,   alypin  in,   693 
eucain  lactate   solution  for,   758 
under  local  anesthesia,  497-499 
Edema  of  tissues  by  morphia-cocain  in- 
jection, anesthesia  by,  808 
Edison's  ansestheticum,   702 
Ehrenfest's   objections   to   spinal   anal- 
gesia in  obstetrics,  594 
Ehrenfried's      apparatus      for      intra- 
tracheal insufflation,  425,  426 
Ehrenfried's    introducing    forceps    for 

stiff  or  soft  rubber  tubes,  427 
Einhorn,    novocain    discovered   by,    482 
Elayl  chlorid.     See  Ethylene  chlorid 
Electric  analgesia,  735 

application  of,  in  man,  633-635 
contra-indications  to,  635 
for   surgical  purposes,   634 
history  of,  628,  629 
in  wireless  circuits,   635,  636 
source  of  current  for,  630 
technique  of,   630-633,   634 
Electric  current  for  dental  anesthesia, 

536 
Electric   resuscitation,    636,    637 
after   accidental  electrocution,   642 
application  of,  in  surgery,  643 
clinical  application  of,  643 
exclusion  of  the  head  in,  637,  638 
kind  of  current  for,  638 
limitations  to,  641,  642 
procedure  for,  638-641 
Electric     sleep,     contra-indications     to, 
635 
distinguished  from  electric  analgesia, 

633 
in   wireless   circuits,    635,    636 
Electricity,  anesthetic  effect  of,  51,  52 

in  local  anesthesia,  477 
Electrocution,       electric       resuscitation 

after,  637,  642 
Electrodes,    application    of,    for    local 

electric  analgesia,   634 
Electrolysis,  preparation  of  oxygen  by, 

894 
Elimination  of  chloroform,  309 


Elimination  of  ether,  107,  108 

of  ethyl  chlorid,  263,  264 
Elliottson,  on  hypnotic  anesthesia,  644, 

645 
Elsberg,  on  anesthesia  by  intratracheal 

insufflation,   416-432 
Elsberg 's    apparatus    for    intratracheal 

insufflation,  419-423 
Elsberg 's    clip     to    hold    intratracheal 

tube  in  place,   428 
Embley,  on  ethyl  chlorid,  258,  259,  260 

on  chloroform,  300,  302 
Emergency    cases,    colonic    ether    anes- 
thesia  contra-indicated   for,   457 
Emphysema,    case   of,    following   intra- 
tracheal  insufflation,   430,    431 
chloroform  indicated  for,  310 
spinal  analgesia  in,  586 
Empyema,  anesthesia  in,  329 

under  colonic  ether  anesthesia,  435 
"  Empyreumatic "    oils    in    chloroform, 

285 
Endoneural  injection   in  local  anesthe- 
sia, 490 
of   the  extremities,  506 
Endopharyngeal       administration       of 
nitrous    oxid    and    oxygen,    159, 
160 
Endopharyngeal  anesthesia,  235-239 
catheters  for,  236 
compared     with     endotracheal,     238, 

239 
essentials  of,  237,  238 
percentage  of  ether  vapor  for,  241 
statistics  for,  856 
Endopharyngeal  insufflation  and  mouth 

tube   combined,    236 
Endopharyngeal    tubes    for    insufflation 

anesthesia,  227 
Endotracheal       anesthesia,       compared 
with    endopharyngeal,    238,    239 
percentage  of  ether  vapor  for,  241 
Endotracheal     insufflation,     in     nitrous 
oxid-oxygen  anesthesia,   173 
statistics  for,  855 
See  also  Intratracheal  insufflation 
Enema  in  preliminary  treatment  of  in- 
testinal tract,  365 
Engelhardt    on    after-effects    of    ether, 
199 
on   effect   of   ether   upon   circulatory 
system,   185 
"English  chloroform,"   876 
English 's   measures   for    shock   preven- 
tion, 403 
Engsted's  method  of  spinal  analgesia, 

598 
Enlarged     tonsils,     administration     of 
nitrous   oxid   in,    140.      See   also 
Adenoid  and  tonsil  cases 
Enophthalmin,   735 
Ensemin,  735 

Enteroepiplocele,     umbilical,     operation 
for,  under  spinal  analgesia,  590 
Enucleation,  anesthesia  in,  338,  339 
Epicain,   735 


912 


INDEX 


Epigastric   hernia   under    colonic   ether 

anesthesia,  436 
Epileptics,  anesthesia  in,  330,  331 
chloroform  indicated  for,   310 
electric     analgesia     contra-indicated 

in,  635 
under    spinal   analgesia,   590,   591 
Epinephrin,   691 

injection   of,    preliminary   to    chloro- 
form anesthesia,   304 
Epirenin    borate    in    spinal    analgesia, 

602 
Epsom  salts,  735 
Erhardt's  solutions,   735 

for  spinal  analgesia,   601 
Erotic    dreams    in   ethyl    chlorid    anes- 
thesia, 265 
Erotic     sensations     during     anesthesia, 

687 
Erythrophlein  hydrochlorid,   735,   736 
Esch,  on  action  of  adrenalin,  540 
Esdaile,  employment  of  hypnotic  anes- 
thesia by,  645,  646 
Esmarch   bandage   in   local   anesthesia, 
477 
in  venous  anesthesia,  490,  492 
Esmarch  inhaler,  204,  206,  217 
Esophageal     strictures     under     colonic 

ether  anesthesia,  454 
Essence   of   orange,   832 
preliminary  use  of,  388 
See   also   Oil   of    bitter   orange   peel 
Esters,  defined,  178 
Ethane,  chlorination  of,  252 
' '  Ethane-oxv-ethane, ' '   178 
Ethene,  736' 
Ethenyl-paradiethoxy-diphenyl  -  amidin 

hydrochlorid,  765 
Ether,  acidity  of,  868,  869 

action     of     hydrochloric      acid     on, 

252 
addition  of,  to  ethyl  chlorid  and  oxy- 
gen in  alcoholics,  278 
administration    of.      See    Ether    ad- 
ministration 
after-effects  of,  199 
American,  purity  of,  869,  870 
and   acapnia,   112 
and  alcohol,  statistics  for,  853 
and  amyl  hydrid,  698 
and  chloroform  in  submucous  opera- 
tions, 340 
nitrous     oxid-ether     sequence     fol- 
lowed by,  325 
statistics  for,  842,  853 
use  of,  in  elderly  people,  328 
and   nitrous  oxid,   141,  142,  143 

statistics  for,  842 
and  oxygen,  87 
in  cancer,  330 
in  heart   disease,  329 
in  insane  patients,  331 
anesthetic,  alcohol  in,  181,   182 
aldehyd  in,  183 
composition  of,   179 
peroxids  in,  182 


Ether,   anesthetic,    standards  of  purity 

to  be  maintained  in,  181 
average  consumption  of,  in  100  cases 

under  colonic  anesthesia,  454 
boiling  point  of,  864,  865 
changes  in,  due  to  improper  storage, 

868 
chemistry  of,  178-184 
chloroform-ether   followed  by,   326 
colonic   absorption  of,   433-458.     See 

also  Ether  administration 
combined     with     ethyl     chlorid     and 

chloroform   (anesthol),  276-278 
containers  for,   182 
early  experimenters  with,   11-19,  434 
effect  of,  on  blood  pressure,  59 
on  the  circulatory  system,  185-188 
on  the   glandular   system,   189 
on  the  muscular  system,  189 
on  the  nervous  system,  188 
on  the  respiratory  system,  185 
effect  of  warming  on,  66 
ethyl  chlorid  and,  279 
ethyl   chlorid   compared  to,   266,  267 
Faraday's  use  of,  5 
fatty    metamorphoses    following    use 

of,  88 
first  use  of,  in  midwifery,  20,  177 
from  ethylene,  862 
from  "methylated"  alcohol,  861 
history  of  use  of,   as  an  anesthetic, 

176-178,   858-860 
hypnotism  and,  645 
impurities   in,    administration   means 

to  avoid,  183-184 
sources  of,  179 
in  A.  C.  E.  mixture,  688,  689 
in  acid  intoxication,  414 
in  cases  of  puerperal  eclampsia,  667 
in  chloroform,  284,  285,  307 
in  cocain  sterilization,  605 
in  convulsive  affections,  667 
in   intravenous   anesthesia,   525,   530, 

532,  533 
in  Schleich's  mixtures,  703,  704,  705 
in     sterilization     of     apparatus     for 

spinal  analgesia,  616 
in  strychnin  poisoning,  667 
in  treatment  of  acute  pain  in  tetanus, 

667 
in  treatment  of  infections,  671-674 

eases  of,   672,   673 
Long's  use  of,   8-10 
manufacture  of,  180,  860-863 
Morton's  experiments  with,  11,  12 
nitrous   oxid-ether   sequence  followed 

by,  325 
peroxids  in,   experiments   of  Basker- 

ville  and  Hamor  on,  182-183 
Pierson's  use  of,  4 
precautions  in  handling,  179 
purity  of,  864-870 
respiratory   failure   due   to,   192 
role  of  water  in,  867,  868 
special  physiology  of,   184 
specific  gravity  of,  864,  867,  868 


INDEX 


913 


Ether,  temperature  stimulus  and,  69 
tests  for  purity  of,  864-867 
use  of  oil  of  bitter  orange  peel  with, 

93,  94 
varieties  of,  in  Great  Britain,  861 
warm,  nitrous  oxid  and  oxygen  com- 
bined with,  325 
with  air,  safety  of,  325 
with    nitrous    oxid    and    chloroform, 

223,  224 
with  nitrous  oxid   and  morphin,   108 
with  oxygen,  safety  of,  325 
See  also  Ethyl  ether 
Ether   administration,   100-103,  199-247 
Allis  inhaler  for,  216 
Bennett  inhaler  for,  218 
by   colonic   absorption,   433-458 
advantages  of,  457 
afferent  and  efferent  tube  systems 

in,  449,  450 
apparatus  for,  437,  438,  441,  442, 

444-449 
cases  of,  435-437,  453-458 
complications  in,  435,  436 
danger  signs  in,  453 
development  of,   441-444 
history  of,  433-439 
indications    and    contraindications 

for,  457,  458 
method  for,  441-444;   450-453 
physiology  of,  439-441 
Sutton's     method     of,     441,     444, 
448 
by  intratracheal  insufflation,  416-432 
causes  of  death  from,  192 
closed  method  of,  177,  217 
Esmarch  inhaler  for,  217 
handkerchief   method  of,   212-217 
open  or  drop  method  of,  198,  199 
as  antidote  to  drugs  used  in  spinal 

analgesia,  598 
Davis's,  205,  206 
droppers  for,  199-202 
in  case  of  acute  mania,  669 
in  locomotor  ataxia,  667 
in  passage  of  renal  or  biliary  cal- 
culi, 667 
masks  for,  202-204 
Mayo's,  203-205 
percentages  of  vapor  for,   241-244 
rebreathing  in,   100-115 
semi-closed  method   of,   211 
Snow 's  inhaler  for,  23 
with  closed  masks,  ill  effects  of,  101, 

102 
with  nitrous  oxid,  218 
with  oxygen,  239,  240 
with  the  ether  rausch,  209-211 
with  warm  water — vapor  inhalations, 
199 
Ether  anesthesia,  after-effects  of,  196- 
199 
blood  changes  due  to,  58 
cone  method  of,  198 
contraindications  to,  328 
brain   operations,   354 


Ether  anesthesia,  diseases  of  respiratory 
passages,  330 
kidney  diseases,  330 
short  operations,  338 
tuberculosis,  329 
danger  of  shock  with,  388 
death  due  to,  841 
discovery  of,  7 
excitement  stage  of,  193 
exhaustion  under,  405 
first    operation    in    England    under, 

19,   177 
in  adenoid  and  tonsil  cases,  340,  341, 
342 
in  children,  327 
in  England,   19 
in  epileptics,  331 
in  Graves'  disease,  353 
in  mastoid  operations,  339 
in  obstetrical  cases,  355 
in  operations  for  cleft  palate,  340 
in     operations     on     the     respiratory 

tract,   339 
in   peritonitis    or    intestinal   obstruc- 
tion, 356 
in  sequestration  anesthesia,  471 
in  status  lymphaticus,  333 
indications  and  contra-indications  of, 

247-249 
indications    of    returning    conscious- 
ness under,  195 
light  stage  of,  193 
normal   surgical   stage   of,   194 
overdose  stage  of,  195 
statistics    for,    842,    843,    848,    853, 
854,  855,  857 
Ether  balance,   maintenance  of,   in  re- 
breathing,  106 
Ether-chloroform-ether  sequence,   326 
Ether-chloroform-oxygen    narcosis,     87, 

88 
Ether-chloroform   sequence,   326 

drop    method    of,    Lumbard's    nasal 

tubes  for,  229 
for  elderly  patients,  234 
heat  resulting  from,   706-710 
statistics  for,  843,  855 
Ether    cMorohydrique,    250.      See    also 

Ethyl  chlorid 
Ether  concentration  in  colonic  anesthe- 
sia, 441 
Ether     controversy     between     Morton, 

Jackson  and  Wells,  17,  18,  19 
Ether  elimination,   107,   196,   379 

effect  of  morphin  on,  108 
Ether  frolics,   7,   9,   177 
Ether  irrigation  of   the  abdomen,  672- 

674 
Ether-menthol-chloroform,   736 
Ether,  morphin  and  scopolamin,  statis- 
tics  for,   842 
Ether  poisoning,  delayed,  440 
Ether  pressure,   242-244 
Ether  rausch,   Coughlin  on,   209-211 
Ether  spray  in  dentistry,  537 

invention  of,  as  local  anesthetic,  477 


914 


INDEX 


Ether  storage,  impurities  developed  in, 

180 
"Ether-tremor,"  194 
Ether    vapor,     administration     of,    by 
Meltzer's  method,  238 
advantages   of,   246 
by  open  method,  231-235 
concentration   of,   240 
effect    of,    on    respiratory    passages, 

101-103 
in  adenoid  and  tonsil  eases,  340,  343 
in  tracheotomy,  353 
mask  for,   232 
maximum   concentration   of,    without 

irritation,    103,    105,   106 
Pinneo's  apparatus  for,  234,  236 
treatment    of    accidents    under,    246, 

247 
use   of,   with   nitrous   oxid   and   oxy- 
gen,  164,   165,   167,   168,   172 
warmed,  25,  225-227 
experiments  with,  70-76 
Gwathmey  's      administration      of, 

231 
temperature  required  for,  227,  228 
Etherization,  open  and  closed  methods 
of,  compared  as  to  toxic  effects, 
102 
Ethical  liability  of  physician,  680,  681 
Ethidene  bichlorid,    750 
Ethidene     dichlorid.       See     Ethylidene 

chlorid 
Ethyl  acetate,  736 

in  chloroform,  285 
Ethyl  alcohol,  737 

in.  chloroform,  283,  289 
in  drop  method  of  ether  administra- 
tion, 182 
in   manufacture    of   ether,    180,    181, 

182 
preparation  of  chloroform  from,  873 
preparation    of    ethyl    chlorid    from, 

252 
presence  of,  in  chloroform,  891 
Ethyl   aminobenzoate,   737,   738 

statistics  for,  843,  856 
Ethyl  bromid,  692,  738-748,  750 

combined    with    methyl    chlorid    and 
ethyl  chlorid    (somnoform),   276 
dosage   for,   739 
Ethyl  carbamate,   838 
Ethyl  chlorid,  20,  27,  691,  692,  748 
after-effects  of,   264,   265 
and  air,  276,  325 

and  chloroform,  115,  116,  279,  285 
rebreathing   in    administration    of, 

115,  116 
statistics  for,  842 
and  ether,  279 

statistics  for,  842,  848,  855 
and  nitrous  oxid,  279 
and   oxygen,    278,   279,    325 

statistics  for,  843,  856 
atropin    as    preliminary    medicament 

to,   373 
bottle  for,  615 


Ethyl   chlorid,   causes   of   death   under, 
261 
chemical   history  of,  250,   251 
combinations     and     sequences     with, 

276-279 
comparison  of,  with  other  anesthetics, 

266,   267 
containers  for,  254-256 
contra-indications   to,    268,    269,   338 
danger  of  shock  with,  388 
dosage  of,  269-271 
effect  of,  on  blood  pressure,  59 
on  circulatory   system,   259,  260 
on  glandular  system,  261 
on  muscular  system,  261 
on  nervous  system,  260,  261 
on  respiratory  system,  258,  259 
effect  of  warming  on,  66 
elimination  of,  263,  264 
experimental   data  on  administration 

of,    269-271 
for  anesthetizing  children,  327 
for  local  anesthesia  in  dentistry,  537, 

538 
history  of  use   of,  as  an  anesthetic, 

251 
impurities  in,  252,  253,  257 

detection  of,  257,  258 
in  convulsions  of  infancy  and  child- 
hood, 667 
in  Meyer's  anesthol,  704,  705 
indications   for,   267,   268 
introduction  of,  into  England,  27 
methods    of    administration   of,    271, 
272 
closed,  273-276 
open,   272 

semi-closed,  272,  273 
nitrous    oxid    with    oxygen    combined 

with,   325 
preliminary    to    puncture    in    spinal 

analgesia,  618,  620 
preparation  of,  251-253 
properties  of,  253,  254 
purification  of,  253 
solubility  of,   in  water  and  in  blood 

serum,  259 
stages  of  anesthesia  with,   261-263 
statistics  for,  842,  843,  848-850,  855, 

857 
storage  of,  254-256 
therapeutic  uses  of,  670,  671 
uses  of,  251 
Ethyl    chlorid-anesthol,    statistics    for, 

843,   856 
Ethyl  chlorid  bengue,  748 
Ethyl  chlorid  C.  P.,  748 
Ethyl        ehlorid-ether-ehloroform        se- 
quence, 206,  325 
Ethyl  ehlorid-ether  sequence,  325 
by  closed  method,  207 
by  drop  method,  206 
for  patients  between  19  and  50,  328 
statistics  for,  843 
Ethyl  chlorid  measure  dropper,  256 
Ethyl  chlorid  polychlorated,  748 


INDEX 


915 


Ethyl  ehlorid  spray  in  local  anesthesia, 

477 
Ethyl  ehlorid   syncope,   261 
Ethyl  ehlorid  toxemia,  261 
Ethyl  ehlorid  tubes,  254-256 
Ethyl  ether,   178,   748 

as  preservative  of  chloroform,  292 

discovery  of,  as  an  anesthetic,  7 
Ethyl  ether-chloroform  mixtures,  748 
Ethyl  formate,  748 
Ethyl  hydrid,   748 
Ethyl  iodid,  748 

action  of  chlorin  on,  252 
Ethyl-morphin  hydrochlorid,  733 
Ethyl-6-anisidin   formate,   749 
Ethyl  nitrate,  749 
Ethyl  nitrite,  749 
Ethylbenzoylecgonin,   725,  738 
Ethylen    689 

Ethylene,  ether  from,  862 
Ethylene  ehlorid,   749 

in  chloroform,  285 
Ethylene  dibromid,  750 
Ethylene  (monochloro-)  ehlorid,  750 
Ethylic  ether,  178 
Ethylidene  dimethyl  ether,  733 
Ethylidene  ehlorid,  750 

in  chloroform,   285 

introduced  by  Clover,  25 
Ethylol,    250,     751.      See    also    Ethyl 

ehlorid 
Ethylpropionyl,   804 
Ethylurethane,  838 
Eucain  in  local  anesthesia,  478 

in  spinal  analgesia,  599 

statistics  for,  842 
Eucain-A,   751-754 
Eucain  acetate,  756,  757 
Eucain-B,   540,   752 

in  local  anesthesia,  482 
Eucain  lactate,  757,  758 
Eucain-snuff  powder,   758 
Eucalyptus  extract,  758 
Eucapren,   758 
Euearenalin,  758 
Eudont,  758 
Eudrenin,  758,  759 
Eugallol,    759 

Eugenic  acid.     See  Eugenol. 
Eugenol,  759 
Eugenol  acetamid,  759 
Eugenol-alcohol,   759 
Eugenol    esters    of    the    aminobenzoic 

acids,  759 
Euphorin,   802,   803.       See  Phenyl-ure- 

thane 
Euprema,   760 
Euroform  paste,  760 
Euscopol,  760 
Eusemin,  760 

Evans,  and  nitrous  oxid,  24 
Excitement  preceding  narcosis,  33 
Excitement  stage,  effect  of  oil  of  bitter 
orange  peel  on,  93,  94,  95 

in  ethyl  ehlorid  anesthesia,   262 

In  nitrous  oxid  anesthesia,  133 


Exophthalmic    goiter,    in     status    lym- 
phaticus,  332,  335 
preliminary   medication   in,   372,   373 
Exophthalmos,  anesthesia  in,  353,  354 
Experimentation,      animal,      with      oil- 
ether  colonic  anesthesia,  458-460 
Extralaryngeal     operations     under     co- 
lonic ether  anesthesia,  435 
Extremities,      operations      on,      eocain 
"block"  in,  402 
intravenous     anesthesia    for,     492, 

506,  509,  511 
under    local    anesthesia,    490,    506- 
512 
Extremities,  lower,  operations  on,  under 
spinal   analgesia,   586,   588,   597, 
610 
upper,  nerve  distribution  of,  508 
superior,  operations  on,  under  spinal 
analgesia,  597 
Eye,  effect  of  eucain-A  on,  751 

enucleation    of,    under    colonic    ether 

anesthesia,  454 
use  of  nervocidin  in,  781 
Eye  surgery,  eucain  lactate  in,  758 
under   colonic    ether    anesthesia,    454 
under  local  anesthesia,  500,  501 
Eyeballs,    in    ethyl    ehlorid    anesthesia, 

263,   274 
Eyelid,  operations  on,  under  local  anes- 
thesia, 497 
separation  of,  in   overdose  of   ethyl 
ehlorid,  261 

Fabre  on  the  effect  of  ether  on  lacta- 
tion, 192 

Face,  changes  in,  due  to  shock,  385 
nerve  supply  of,  497 

Face  mask,  Teter,  for  nitrous  oxid-oxy- 
gen  anesthesia,  154 

Facial  operations,  chloroform  indicated 
for,  310 
under  local  anesthesia,  497,  498 

Fainting,  following  ethyl  ehlorid  anes- 
thesia, 265 

Faivre  on  spinal  analgesia,  564 

Falkenstein 's  zahnpasta,  760 

False   chloroform  anesthesia,   380 

Faraday  on  ether,  5,   177 

Farina  cologne  in  chloroform  adminis- 
tration, 312,  316 

Fatty  degeneration  of  kidneys  and 
liver,  following  repeated  admin- 
istrations  of   ethyl   ehlorid,    265 

Fatty  metamorphosis  and  anesthesia, 
88,  90 

Favill  on  acid  intoxication  due  to  anes- 
thetics,  414 

Fear,  diagnostic  evidences  of,  368,  369 
prevention  of,  388 

prior    to    anesthesia,    effect    of,    366, 
369,   370 

Fedorow  on  intravenous  anesthesia,  524 

Ferguson 's  artificial  airway,   39 1 

Ferguson's  ethyl  ehlorid  tubes  for  gen- 
eral and  local  anesthesia,  255 


916 


INDEX 


Ferguson's  mask  for  ether  administra- 
tion, 203,  204 

Fetus,  effect  of  ether  upon  the,  191 

Fever  after  spinal  analgesia  with  tropo- 
cocain,  583 

Fevers,  infectious,  acidosis  in,   415 

Field,  Justice,  legal  status  of  physician 
determined  by,  678,  679 

Filliatre  on  cocain  in  spinal  analgesia, 
600 

Filodentol  BertagnoUi,  760 

Finger,   cross-section  of,   509 

Finger  anesthetization,  507 

Finger  operations,  354 

Esmarch  elastic  bandage  in,  477 

Finnemore  and  Wade  on  alcohol  pre- 
pared from  ethyl  alcohol,  882 

Fischer's  apparatus  for  intratracheal 
insufflation,  423,  425 

Fischer's  "normal  anesthetic  solu- 
tion," 541 

Fisher  on  paralyses  after  spinal  anal- 
gesia, 584 

Fistula  in  ano,  colonic  ether  anesthesia 
contra-indicated  in  case  of,  457 

Flexible  spraying  nozzle  for  ethyl 
chlorid,  254 

Flushing  of  face  associated  with  ethyl 
chlorid   anesthesia,   260 

Foot,  removal  of  tuberculous  abscesses 
of,  under  spinal  analgesia,  575, 
576 

Foramen  ovale,  section  through,  500 

Forbes,  Sir  John,  on  hypnotic  anes- 
thesia, 644 

Forearm,  cross-section  of,  507 

Forel's   classification   of   hypnosis,   654 

Forel's  method  of  inducing  hypnosis, 
658 

Formal,    776,   777.      See   also   Methylal 

Formaldehyd,  689 

in  testing  chloroform  for  impurities, 
890 

Formaldehyd-kelene,  760 

Formanilid,    760 

Formic   acid,   formation   of,   on   expos- 
ure of   chloroform  to   light,   884 
in   chloroform,    285,   286 

Formic  ether,  748 

Formyl  tribromid.     See  Bromoform 

Formyl  trichlorid,  281.  See  also 
Chloroform 

Fortescue-Brickdale,  on  methyl  ether, 
776 

Foureroy  on  ether,  860 

Foy,   George,   on   chloroform,   26 

Fractures,  treatment  of,  under  colonic 
ether  anesthesia,  454 
under    infiltration    of    cocain    and 

adrenalin,  508,  509 
under   intravenous   anesthesia,   492 

Fraicon's  auto-operation  under  spinal 
analgesia,   577 

Fraicon's  solution  for  spinal  analgesia, 
577 

Francis,  on  methyl  ether,  776 


Freezing  as  a  means  of  local  anesthe- 
sia, 537 
in  anesthetization  of  skin,  493 
with  anaesthyl,  710 
with  ethyl  chlorid  as  local  anesthetic, 
477,   670 

French   on    sequestration   with   upright 
position,  473-475 
on  use  of  oil  of  bitter  orange  peel, 
94 

French  chair  table,  346-351 

French  Codex,  ethyl  chlorid  tests  pre- 
scribed by,  258 

French  method  of  adenoid  and  tonsil 
operations  in  upright  position, 
345-352 

Fresenius  ansesthesin-bormelin.  See 
Anaesthesin-bormelin 

Frink,  H.  W.,  on  hypnosis,  653-665 

Frink  's  method  of  inducing  hypnosis, 
658-664 

Fritsche's  method  of  preparing  ether 
from  ethylene,  862 

Frobenius,  experiments  of,  with  ether, 
859,   860 

Frohmann's  solution,  760 

Furfurane,   714 

Furniss  gas-ether  inhaler,  220 

Gajacyl.     See  Guaiacyl 

Gall-bladder   operations,   shock   in,   403 

under  local  anesthesia,  518,  519 
Gallotannic     acid     as     preservative    of 

chloroform,  292 
Ganglia,    sympathetic,   excision   of,   un- 
der spinal  analgesia,  587 
Ganglion   cells,   effect   of   ethyl   chlorid 
on,   260 
in  anesthesia,  34,  36,  37 
role   of,   in  ethyl   chlorid  anesthesia, 
264 
Gangrene   from  Esmarch   elastic  band- 
age, 477 
of    intestine,    operation    for,    under 

spinal   analgesia,  593 
senile,  spinal  analgesia  in,  587 
Gas-ether-chloroform   sequence,    326 
in  adenoid  and  tonsil  cases,  342 
Gas-ether  sequence,  326 

contra-indicated    in    elderly    people, 

328 
for  patients  between  19  and  50,  328 
in  adenoid  and  tonsil  cases,  342,  343 
in   nervous   patients,    330 
Gasoline,  761.     See  also  Pentane 
Gasserian    ganglion,    cannula    insertion 
for,  according  to  Haertel,  501 
injection  of,  in  local  anesthesia,  498 
removal  of,  under  colonic  ether  anes- 
thesia, 454 
Gasserian  ganglion  puncture  according 
to  Haertel,  498 
skin  wheal  for,  500 
Gastralgia,  ethyl  aminobenzoate  in,  737 
Gastric  ulcer,  acidosis  in,  415 
antemesin  in,  711 


INDEX 


917 


Gastric  ulcer,  use  of  orthoform-new  in, 

789 
Gastro-enterostomy,   anesthesia   in,   356 
hypodermoclysis  in,   376 
under  local  anesthesia,  518 
Gasu-basu.     See  Nervocidin 
Gatch,    W.    D.,   on    rebreathing   in   ad- 
ministration   of    anesthetics,    27, 
100-116 
Gatch 's    method    of    administering    ni- 
trous  oxid    and   oxygen,    144-151 
Gatch 's  nitrous  oxid-oxygen  apparatus, 

104 
"Gauze  ether"  method,  102 
Gebauer    container    for    ethyl    chlorid, 

256 
Gebauer    tube    for    administration    of 
ethyl  chlorid  in  dental   anesthe- 
sia, 537 
General   anesthesia,   theories   of, 
Baglioni's,  46 
Bernard's,  34 
Binz's,   34 
Barker's,   48 
Dubois',  34,  35 
Gill's,  46 
Gros's,  48 
Hober's,  46 
Lillie's,  50-55 
Mathews-Brown,  42-44 
Meyer-Overton,  37-40 
Moore-Eoaf,  44-46 
MuUer's,  36,  37 
Eeicher's,  47,  48 
Schleich's,  35,   36 
.     Spencer's,  32-34 
Traube's,  42 
Verworn's,  49,  50 
Wright's,  40-42 
General   anesthetics,   chief,   32 
definition  of,  31 
requirements  of,  31,  32 
Genitals,  external,  site  of  spinal  punc- 
ture for  operations  on,  610 
Genito-urinary    diseases,    sanovagin    in, 

727 
Genito-urinary     operations,     anesthesia 
in,  355 
under  local  anesthesia,  512,   513 
under  spinal  analgesia,  560,  587 
Geraniol,  as  preservative  of  chloroform, 

292 
German  chloroforms,  876,  877 
Gerstenberg    on    spinal   analgesia,    564, 

621 
Gessner,  Conrad,   858 
Geuther,     preparation     of     chloroform 
from  carbon  tetrachlorid  by,  875 
Gibbs'    method    of    purifying    chloro- 
form,  879 
Giesel,    discovery    of    tropacocain    by, 

832 
Gill  on  chloroform,  297,  299,  305 
Gill's  theory  of  anesthesia,  46 
Giswold  on  use  of  quinin  and  urea  hy- 
drochlorid,   806 


Glacial,   761 

Gland  removal  from  neck  under  spinal 

analgesia,   587 
Glands,   enlarged,   chloroform  indicated 

for,   310 
Glandular  system,  effect  of  anesthetics 
on,  60,  61 
effect   of  /Jhloroform   on,   303-305 
effect  of  ether  on,   189 
effect   of  ethyl  chlorid   on,   261 
effect  of  nitrous  oxid  on,  131,  132 
Glass  containers  for  ethyl  chlorid,  255, 

256 
Gleditschin.     See  Stenocarpin 
Glottis,  closure  of,   by  the  tongue,  390 
Glucose  in  dietetic  shock,  387 

in    spinal    analgesic    solutions,    599, 

602,  603 
use  of,  preceding  anesthesia  in  can- 
cer, 330 
Glucose-adrenalin-stovain      solution      in 

spinal  analgesia,   625 
Glycogen,  importance  of,  in  liver,  dur- 
ing anesthesia,  365,   366 
Glycosuria  in  ether  narcosis,  191,  196- 

198 
Goiter,  anesthesia  in,   353,  354 

operations    for    under    colonic    ether 
anesthesia,  454 
under  local  anesthesia,   502-505 
under  spinal   analgesia,   580 
sequestration  anesthesia  indicated  in, 
469 
Goldan  on  spinal  analgesia,  567 
Goldschmidt 's  anaesthetics,  761 
Goldstein,  experiments  of,  with  nitrous 

oxid,  126,  127 
Goyanes  on  arterial  injection,  478,  492 
Graham's  theory  of  etherification,  863 
Graves'  disease,  anesthesia  in,  353,  354 
use  of  scopolamin  contra-indicated 
in,  815 
Gray  on  eucain-B,  755 

on    spinal    analgesia,    587,    588,    589, 
590,  598 
dextrin-stovain   solution  by,   603 
site  for  spinal  puncture  by,  610 
Gray's  auEestheticum,   702,   761 
Grayson's  statistics  for  chloroform,  852 
Gregory,  on  chloroform  prepared  from 

ethyl  alcohol,   882 
Gregory's  method  of  purifying  chloro- 
form. 878,  879 
Grehant's  anesthetic,   761 
Groin,  diffuse  mfiltratiou   in,  510 

removal    of    glands    of,    under    local 
anesthesia,   485 
Grondahl  on  effect  of  ether  on  the  kid- 
neys,  189 
Gros,  conclusions  of,  on  relation  of  gen- 
eral and  local  anesthetics,  48 
on    novocain    bicarbonate     solutions, 
786 
Gross  ignorance  or  negligence,  on  part 

of  physician,  685,  686 
Groves,  J.  F.,  on  Long,  8 


918 


INDEX 


Grube   on   effect   of   ether   upon   body 
temperature     and     carbohydrate 
metabolism,   197 
on  glycosuria  in  ether  narcosis,   191 

Guaiacol,  761,  762 

as  preservative  of  chloroform,  292 

Guaiacyl,   762 

Guaiasanol,  762 

Guajacid,    762 

Gujasanal.     See  Guaiasanol 

Gum  acacia,  addition  of,  to  tropaco- 
cain,  837 

Gum  arable  in  spinal  analgesic  solu- 
tions,  599,   601 

Gummitropakokain,  763 

Gums,  operations  on,  under  local  anes- 
thesia, 497 

Guthrie,  discovery  of  chloroform  by, 
871,  872 

Guthrie  and  Eyan  on  magnesium  salts, 
771 

Gwathmey,  anesthetization  of  a  case  of 
acute  mania  by,  668-630 
experiments    of,    on    warming    anes- 
thetic agents,  63-66,  69 
with   oxygen   combined   with   anes- 
thetic agent,  82-86 
use  of  oil  of  bitter  orange  peel  by, 
92,  93 

Gwathmey  inhaler,  for  nitrous  oxid- 
ether  sequence,  218,  219,  220 

Gwathmey  method  of  nitrous  oxid-oxy- 
gen  anesthesia,  153 

Gwathmey  nitrous  oxid-oxygen  appar- 
atus,   150 

Gwathmey  oxygen  Y-piece,  151 

Gwathmey    rectal   irrigating   tube,   461 

Gwathmey  three-bottle  vapor  inhaler, 
317,  323,  334 

Gwathmey  vapor  apparatus,   71,   72 

Gwathmey  vapor  inhaler,   147,  148 

Gwathmey  and  Alexander  on  adenoid 
and  tonsil  cases,  340-352 

Gwathmey  and  Baskerville,  experiments 
of,  on  warming  ether  vapor,  71- 
73 

Gwathmey-Woolsey  mask  for  nitrous 
oxid-oxygen  anesthesia,   172 

Gwathmey-Woolsey  nitrous  oxid-oxygen 
apparatus,  170-175 

Gynecology,  ethyl  chlorid  anesthesia  in, 
.268 
local  anesthesia   in,   516 
use  of  scopolamin  in,  813,  814 
use  of  tropacocain  in,  836 

Haertel's    method    of    nerve    blocking, 
498 
of  reaching  Gasserian  ganglion,  501 

Hager  on  effect  of  light  on  chloroform, 
884 
on  "English  chloroform,"  876 

Halbreich's  experiments  on  cerebro- 
spinal fluid  diffusion,  566 

Hallucinations,  due  to  nitrous  oxid, 
131 


Hallux    valgus,    injection    of    skin    in- 
cision for,  510,  511 
Hamblen    on    acetonuria    after    ether, 

198 
Hamor  and  Baskerville,   on  decomposi- 
tion  of  chloroform,   887-889 
Handkerchief  method  of  ether  adminis- 
tration, 212-215 
Harcourt's  inhaler,  26,  320,  321 
Harley,  "A.  C.  E. .mixture"  by,  23 

on   spinal   analgesia,   556 
"Hashish,"  3 

Hassler,  J.  Wyllis,  on  intravenous  anes- 
thesia, 523-534 
Hatcher,  on  scopolamin,  815 
Hawk  on  effects  of  ether  on  the  urine, 
197 
on  glycosuria  after  ether,  196 
Hay  fever,  formaldehyd-kelene  in  treat- 
ment of,  760 
rhinosol  for,  808 
use  of  orthoform-new  in,   789 
Hayden    on    surgery   under    anesthesia, 

14-16 
Hay  ward  on  Bier,  492 

on  chloroform,  25 
Head,   exclusion   of,   in   electric  circuit 
for    resuscitation,    637,    638 
operations  on,  colonic  ether  indicated 
in,   457 
intratracheal  insufflation  indicated 

in,  431 
under  local  anesthesia,  496-501 
under  spinal  analgesia,  597 
Head    and    neck    cases    under    colonic 

ether  anesthesia,  436 
Headache  after  spinal  analgesia,  583 
following    ethyl    chlorid    anesthesia, 
264,   265 
Healing  after  local  anesthesia,  488 
Heart,  action  of  chloroform  upon,  299, 
301,   317 
concomitant     affections     of,     spinal 
analgesia      contra-indicated      in, 
587 
effect  of  anesthetics  on,  59 
effect  of  ethyl  chlorid  on,  258,  259, 

260 
effect  of  nitrous  oxid  on,  130 
effect    of    nitrous    oxid    and    oxygen 

on,   670 
effect  of  shock  on,  385 
effect  of  warming  the  anesthetic  on, 
65 
Heart  disease,  choice  of  anesthetic  in, 

328,  329 
Heart  failure,  death  due  to,  in  status 

lymphaticus,   333 
Heart  lesions,  colonic  ether  anesthesia 

indicated  in,  457 
Heat   during   colonic   ether   anesthesia, 
458 
effect  of,  on  ethyl  chlorid,  253 
from  ether  and  chloroform  combina- 
tion,  705-710 
moist,  as  preventive  of  shock,  402 


INDEX 


919 


Heat.        See   also    Warming    the    anes- 
thetic agent 
' '  Heavy  oil  of  wine, ' '  864 
Hedonal,  763,  764 

in  intravenous  anesthesia,  532,  533 
Hein  on  spinal  analgesia,  564,  621 
Helleborein,  764 
Hellman,    on    training   of    anesthetists, 

676 
Hemoglobin,  role  of,  in  anesthesia,  44, 

45 
Hemorrhage,   control   of,  by   sequestra- 
tion   anesthesia,    468,    470,    473- 
475 
during  anesthesia,   saline  enema  for, 
376 
with   colonic   ether,   436,    455,   456 
post-operative,    in    local    anesthesia, 
483 
Hemorrhoids,     operations     for,     under 
local  anesthesia,  485 
use     of     suppositoires     adreno-styp- 
tiques  in,  830 
Hemostatic  cocainol  bougies,  727 
Henderson,   101,  388,  406 

on  acapnia   as   cause   of   shock,   401. 

on  acapnia  in  rebreathing,  112 

on  arterial  pressure  due  to  shock,  408 

on  death  due  to  ether,   192 

on   physiological   role   of   carbon   di- 

oxid,  97,  98 
on  vasomotor  hyperactivity  as  cause 

of  shock,  406-409 
use  of  magnesium  chlorid  by,   771 
Hennell,  observations  of,  on  etherifica- 

tion,   862 
Henry  VIII,  medical  profession  estab- 
lished under,  678 
Hernia,   abdominal,    operation  for,   un- 
der  oil-ether   colonic   anesthesia, 
464 
femoral,    operation    for,    under   local 

anesthesia,  522 
inguinal,   cure   of,   under   local   anes- 
thesia, 519-523 
operation   for,   under    spinal   anal- 
gesia,   579,   580,    588,    591,    625, 
626 
post-operative  ventral,  operation  for, 

under  local  anesthesia,  523 
recurrent,   operation  for,  under  local 

anesthesia,  522 
umbilical,  operation  for,  under  local 
anesthesia,  522,  523 
scheme  of  injection  in,  522 
Hernia    incision,    relation    of    inguino- 

scrotal  nerves  to,  520 
Hernia    operations,    ether    disinfection 
in,  672,  673 
under   colonic    ether    anesthesia,    441 
under  local  anesthesia,  485,  486,  490, 

519,  521 
under  spinal  analgesia,  577,  625 
Herrenknecht,  267 

on     ethyl    chlorid    anesthesia,      262, 
263 


Hertel's  solution  for   spinal  analgesia, 

601 
Hertzler    on    urea    and    quinin    hydro- 
chlorid   as  local  anesthetic,  483, 
500,   515 
Hervey   on   warmed   ether   vapor,    229- 

231 
Heufiber-renitol,    764 
Heufibrol-cr^me   Stauffer,   764 
Hewitt,   Frederick  D.,   3,   8,   832 

on    administration    of    nitrous    oxid 

with   air,    141 
on     causes     of     death     under     ethyl 

chlorid  anesthesia,  261 
on  combining  oxygen  with  anesthetic 

agent,   80,  81 
on    effects   of   chloroform,    285,   305, 

667 
on  ethyl  chlorid  anesthesia,  267,  271 
on   methylated   ether,    861,   862 
on  nitrous  oxid  and  oxygen,  25 
on  nitrous  oxid-ether-chloroform,  852 
on   oxygen-ether   administration,   239 
on   respiratory  failure   due  to  ether, 

192,   193 
statistics     of,     for     ether     and     for 
chloroform,   852-854 
Hewitt's  artificial  airway,  390,  391 
Hewitt's  breathing  tube  in  intravenous 

anesthesia,  530 
Hewitt's  C.  E.  mixture,  764 
Hewitt's      method,      of     administering 
ethyl  chlorid,  275,  276 
of    nitrous     oxid-oxygen     anesthesia, 
151-153,   161 
Hewitt-Mason's   mouth-gag   with   anes- 
thetic tubes,  322 
Hexachlor-benzene  in  chloroform  decom- 
position, 295 
Hexachlorethane  in  chloroform,  285 
Hexahydrophenanthrene,   764 
Hexamekol,  764,  765 
Hexane,    765 

Hiccough  during  anesthesia,  381 
Hickman,  Henry  Hill,  5-7,   719 
High    arterial    pressure,    electric    anal- 
gesia contra-indicated  in,  635 
History  of  anesthesia,  1-29 
H.  M.  C,  ether  and,  statistics  for,  856 
Hober's  theory  of  anesthesia,  46 
Hoffmann,    on    temperature    in    ether- 
drop-anesthesia,  69 
preparation  of  ether  by,  859 
Hoffman 'sche  Tropfen,  859 
Hohmeier,  on  death  due  to  spinal  anal- 
gesia,   598 
Holocain   and   adrenalin   ointment,   765 
Holocain  hydrochlorid,  765 

hydrochlorid     in      spinal     analgesia, 
563,  599 
Holscher   on   effect   of   ether  vapor   on 

the  lungs,  102 
Homatropin,   688 
Homeopathy  and  allopathy,   678 
Honan,     William    F.,     on    intravenous 
anesthesia,  523-534 


920 


INDEX 


Hooker's    tracing    showing    effect    of 

weak    ether     vapor     on    pyloric 

ring  of  frog,  114 
Hoseman  on  lumbar  pressure,  583 
Houghton     on     spinal     analgesia    with 

Barker  solution,  602 
Humphrey's    "Medicated    Vapors,"    7 
Hutchinson,     anesthetic     properties     of 

induction  currents  discovered  by, 

628 
Hyderabad  Chloroform  Commission,  26 
Hyderabad  Commission,  on  cardiac  in- 
hibition,  302 
Hydramyl,   697,   767 
Hydramyl  ether,   767 
Hydramyle,  767,  768 
''Hydrate  of  ether,"   178 
"Hydrate   of   ethylene,"   178 
Hydriodic  ether,   748.     See  also  Ethyl 

iodid 
Hydrobromic  ether,   738-748.     See  also 

Ethyl    bromid 
Hydrocele    under    colonic    ether    anes- 
thesia,  454 
under     oil-ether     colonic     anesthesia, 

464 
Hydrochloric   acid   in   chloroform,   285, 

286,  293,   294 
in     chloroform     decomposition,     296, 

883-888 
in     preparation     of     ethyl     chlorid, 

252 
test  for,  in  ethyl  chlorid,  257 
Hydrochloric     ether,     250.       See     also 

Ethyl  chlorid 
Hydrogen,  discovery   of,  4 
Hydrogen   chlorid   as   product   of   pure 

chloroform    decomposition,    290 
in  preparation  of  ethyl  chlorid,  252 
Hydrogen  dioxid,   364 
in  chloroform,   286 
in   disinfection   of   mouth,   364 
Hygienic      treatment     preliminary     to 

anesthesia,  364-366 
Hyndham  and  Mitchener  on  magnesium 

sulphate,  771 
Hyoscin    in    post-operative    treatment, 

378 
in  preliminary  medication,  371 
for  spinal  analgesia,  612 
Hyoscin    hydrobromid    in    preliminary 

medication   for   oil-ether   colonic 

anesthesia,    461.      See   also    Sco- 

polamin  hydrobromid 
Hyoscin-morphin-cactin        combination, 

372,   768.     See  also  H.  M.  C. 
Hyoscin-morphin  mixture,   768 
Hypercapnia  in   rebreathing.    111 
Hyperoxygenation     theory     of     nitrous 

oxid  action,  123,   124 
Hyperpnea    following    overdose    of    ni- 
trous oxid,   134 
in  anesthesia,  380,  389 
Hypersensitiveness  to  anesthetics,  832 
Hypertension,    sequestration   anesthesia 

contra-indicated  in,  470 


Hyperthermia    after    spinal    analgesia, 

582 
Hyperthyroidism,  354 
Hypnosis,     different    degrees    of,    654, 
655 
induction   of   anesthesia   under,    664, 

665 
methods  of  inducing,  657-664 
Hypnotism,   2,   644-653 

advantages  of,   in  anesthesia,   647 

anesthesia  by,  644-646 

attitude    of    the    hypnotist    in,    656, 

657 
charlatanism  and,  649 
chemical   anesthetics    and,    645-647 
disadvantages  of,  648,  649 
early  history  of,  4 
factors  influencing,   655,   656 
in  childbirth,  647,  648 
in  minor  operations,  648 
Hypochlorites,    preparation    of    oxygen 

from,  894 
Hypodermic  apparatus,  484 
for  dental   use,   542,  543 
Hypodermic  injection  in  shock  preven- 
tion, 403 
prior  to  local  anesthesia,  486 
Hypodermic  method  of  local  anesthesia 
in    dentistry,    requirements    for, 
536,  537 
Hypodermic  syringe,  invention  of,  478 
Hypodermoclysis  in  gastro-enterostomy, 
356,  376 
in  treatment  for  shock,  374 
Hypophosphorous   acid   as   preservative 

of  chloroform,   292 
Hypotaxis,   654 

Hysterectomy,  abdominal,  under  anoci- 
association,  405 
under  spinal  analgesia,  560 
Hysteria,  control  of,  374 
use  of  hedonal  in,   764 
Hysterical    symptoms    following    ethyl 
chlorid  anesthesia,  265 

Ice  and  salt,   768 

Ice  packs  for  painless  dentistry,  537 

Ichnol,   768 

Icterus,  post-operative,  following  se- 
questration anesthesia,  472 

von  Idelson  on  chloroform  and  oxygen, 
27 

Idin,  768 

Idiosyncrasy  and  failure  to  produce 
spinal   analgesia,    585,    623,    624 

Idiosyncratic  difficulties  during  anes- 
thesia,  832 

Idiots,  psychic  treatment  for,  prelim- 
inary to  anesthesia,  366 

Illegal  operations,  law  relating  to 
anesthesia  in,  687 

Incision  through  skin  and  platysma 
muscle   in   goiter   operation,   504 

Incisive  fossa,  location  of,  551 

Induction  currents,  production  of  anes- 
thesia by,   628,   629 


INDEX 


921 


Infants,  selection  of  anesthetic  for,  326 
Infections,    ether    treatment    of,    671, 

672 
Inferior   maxilla   operations   under   co- 
Ionic  ether  anesthesia,  454 
Infiltration    in    anesthesia    of    the    ex- 
tremities, 506,  508,  509 
in  anesthetization  of  skin,  493 
in  excision  of  varices,  511 
in  external  urethrotomy,  512 
in  eyelid  operations,   497 
in  facial  operations,   497 
in  gynecology,  516 
in  hernia  anesthetization,  522,  523 
in  larynx  surgery,  502 
in  local  anesthesia,  489 

solution  for,  480 
in   local  jaw  operations,  498 
in  mouth  operations,  497 
in  nasal  operations,  497 
in  neck  surgery,   501 
in  operations  on  cheeks,  497 
in  operations  on  gums,  497 
in  outer  ear  operations,  497 
in  scalp  wounds,  496 
in  thyroid  operations,  503 
in  tongue  excision,  497 
in  tracheotomy,  502 
Schleich's,   in    spinal   analgesia,    559 
submental,    in    lower    lip    operation, 
498 
Infiltration   anesthesia,    anesin,   in,    711 
Barker's  anesthetic  in,   713 
eucain-B  in,   756 
eucain  lactate  solution  for,  758 
solutions   for,   693 
Infusion  in  shock  prevention,  403,  404 
Inguinal    glands,    enlargement    of,    in 

status   lymphaticus,   332 
Inguinal    hernia     operation     under  co- 
lonic ether  anesthesia,  454 
under  local  anesthesia,  493 
under  spinal  analgesia,  579,  580,  588, 
591,  625,  626 
Inguinal  region,  operations  in,   site   of 

spinal  puncture  for,  610 
Inhalation  anesthesia,   discovery   of,   3, 

7 
Inhalation    anesthetics,    list    of,    based 
on  safety  to  life,  325 
therapeutic  uses  of,  666-674 
Inhaler,   Allis,   216 
Bennett,   218 
Esmarch,  217 
Furniss  gas-ether,  220 
Gwathmey,  218,  219,  220 
Hareourt's,  320,  321 
Inhibition,  cardiac,   duo  to  chloroform, 

302 
Injection  Hirsch,  768 
Injection  in  spinal  analgesia,  technique 

of,  617-623 
' '  Inogen ' '   compounds  in  nervous   sys- 
tem,  effect  of  anesthesia  on,  47 
Inosit -mono -methyl  ether  as  preserva- 
tive of  chloroform,  292 


Insane  patients,  anesthesia  in,  331 
chloroform  indicated  for,  310 
psychic    treatment    for,    preliminary 
to  anesthesia,  366 
Insanity    following    administration    of 

anesthetic,  832 
Insomnia     after     subarachnoid     anal- 
gesia, 583 
anesthetic  treatment  for,  667,  668 
induction  of  electric  sleep  in,  633 
use  of  hedonal  in,  764 
Instillation   of   cocain   in   eye   surgery, 

501 
Insufflation,   endopharyngeal.     See   En- 
dopharyngeal  anesthesia 
endotracheal.      See   Intratracheal   in- 
sufflation 
Insusceptibility  to  anesthetics,   832 
Intestinal     obstruction,     anesthesia    in, 
356 
in  children,  spinal  analgesia  in,  589 
intratracheal  insufflation  in,  432 
Intestinal  operations  under  local  anes- 
thesia, 518,  521 
Intestinal  tract,  care  of,  preliminary  to 

anesthesia,  365 
Intestines,    effect    of    temperature    on, 

during  anesthesia,  386 
Intra-abdominal  administration  of  oxy- 
gen,  89,   90-92 
Intra-arterial  anesthesia,  492,  493 
Intralaryngeal  operations  under  colonic 

ether  anesthesia,  436 
Intranasal    operations,     anesthesia    in, 

340 
Intra-osseous    injection    of     anesthetic 

solutions  in  dentistry,  547,  548 
Intratracheal      insufflation,      apparatus 
for,  419 
bibliography  on,  432 
course  of  anesthesia  by,  429,  430 
definition  of,  416 
history  of,  416-419 
in  prevention  of  acapneal  respiration, 

409 
indications  for,  431,  432 
statistics  for,  843,  852,  855 
technique  of,  426-429 
errors  in,  430,  431 
value    of,   as   a   method   of    artificial 
respiration,  432 
Intravenous  anesthesia,  523-534 

administration  of  anesthetic  in,  529, 

530 
after-treatment  in,  530-532 
apparatus  for,  525,  530,  531 
blood  changes  in,  533,  534 
history  of,  523,  524 
mixed  forms  of,  532,  533 
of  extremities,  506,  509,  511 
patient  under,  530 
physiology  of,  524 
preliminary    narcosis    in,    370,     524, 

532,  533 
selection  of  vein  for,  525,  526 
solutions  for,  525,  529 


922 


INDEX 


Intravenous    anesthesia,    technique    of, 
524-532 
urinary  examination  in,  534 
Intravenous    infusion    in    serious    cases 

of  shock,  404 
Intussusception      in      children,      spinal 

analgesia  in,   589 
lodin,  preliminary  use  of,  in   oral  sur- 
gery, 543 
in  post-operative  vomiting,  379 
in  spinal  injection,  617 
in  sterilization  of  skin,  615 
tincture  of,  692 
Iodoform,  768 

photochemical  oxidation  of,  888 
lonone,  as   preservative  of  chloroform, 

292 
Iridectomy,  use  of  chloroform  in,  338 
Ischemia  in  venous  anesthesia,  490-492 

of  gut,  443 
Isoamyl  hydrocuprein,   805 
Isoamyl  nitrite.     See  Amyl  Nitrite 
Iso-amylene-beta-pental,  768 
Isobutyl,  805 
Isobutyl     ester     of     para-amidobenzoic 

acid.     See  Cycloform 
Isopon,  768.     See  also  Pantopon 
Isopral,  768,  769 

in  intravenous  anesthesia,  532 
in    preliminary    medication    for    oil- 
ether  colonic  anesthesia,  461 
Isopropyl,  805 

Jaboulay  on  spinal  analgesia,  558 

Jackson,  Charles  T.,  8,  12,  14,  16-19 

Jackson's  direct  laryngoscope,  428 

Jackson's  speculum,  226 

James'    method    of    inducing   hypnosis, 
657 

Janeway's  apparatus  for  intratracheal 
insufflation,  423,  424 

Jaundice   following  ethyl  chlorid  anes- 
thesia, 265 

Jaw  excision,  under  colonic  ether  anes- 
thesia, 435 
under  local  anesthesia,  490,  498,  511 

Jehnol,  769 

Jessel  and  Orndorff,  on  preparation  of 
chloroform  from  acetone,  874 

Johimbin.     See  Tohimbin 

Jonnesco  's  method  of  spinal  analgesia, 

562,  563,  576,  582,  583,  586,  591, 

595,  597,  603,  604,  610,  622 

mortality  record  in  cases  under,  597 

site  of   spinal  puncture  in,  607,  608 

Jonnesco 's     stovain-strychnin     solution 
for,  582,   603 

Josson  warmed  ether  vapor,  228 

Jouanin  on  nirvanin,  781,  782 

Juilliard's  statistics,  854 

Junker    apparatus    for    chloroform    ad- 
ministration, 321,  322 

Junker  chloroform  bottle,  226 

Junker  inhaler,  24,  27,  228,  314 

modification  of,  for  ether  by  Braun, 
178 


Kandol.     See  Canadol 
Kappeler,  on  decomposition  of   chloro- 
form, 884 
on  ethyl  acetate,  736 
on  morphin  hydrochlorid,  779 
Katharin.     See  Carbon  tetraehlorid 
Keen's  prevention  of  shock,  383,  404 
Kelen,  250,  769.    See  also  Ethyl  chlorid 
Kelene,  537,  760 
Kelene-methyl,  769 
Kemp,    experiments   of,    with   nitrogen 

and  nitrous  oxid,  125 
Keroselene,   769 

introduction  of,  24 
Kessler,  on  purification  of  chloroform, 

878 
Ketopropane,  689.     See  also  Acetone 
Kidney  lesions,  colonic  ether  anesthesia 

indicated  for,  457 
Kidney  removal  under  local  anesthesia, 

519 
Kidneys,    care    of,    during    anesthesia, 
374 
concomitant     affections     of,      spinal 
analgesia      contra-indicated      in, 
587 
diseases  of,  anesthesia  in,  330 
ether  contra-indicated  in,  248 
sequestration  anesthesia  in,  473 
eifect    of    chloroform    on,    303,    304, 

309 
effect  of  ether  on,  189-191,  248 
effect  of  nitrous  oxid  on,  132 
effect  of  shock  on,  385 
effect  of  spinal  analgesia  on,  583 
elimination  of  ethyl  chlorid  through, 

264 
fatty   degeneration  of,  following  re- 
peated   administration    of    ethyl 
chlorid,  265 
preliminary  treatment  of,  dosage  for, 
364 
Kinderjy  on  spinal  analgesia,  561 
Kit  of  anesthetist,  362,  363 
Klapp  's     technique     for     sequestration 

anesthesia,  471 
Klikowitsch   on  nitrous   oxid   and   oxy- 
gen, 670 
Klose  on  spinal  analgesia,  565,  571 
Knee     resection     under     colonic     ether 

anesthesia,  454 
Kocher  on   contraindications  to  ether, 
248 
on    local    versus    general    anesthesia, 

485 
on     thyroid     operation     under     local 
anesthesia,  502 
Koenig's      aether      anaestheticus.        See 

^ther  anaestheticus 
Kohler   on    death    due    to    spinal   anal- 
gesia, 598 
KoUer,  cocain  advocated  by,  536  , 
Keller's  use  of  cocain  in  surgery,  478, 

556 
Konig     on     administration     of     ethyl 
chlorid,  269 


INDEX 


923 


Konig  on  after-effects  of  ethyl  chlorid 
anesthesia,  264,  265 

Kreis's  use  of  spinal  analgesia  in  ob- 
stetrics, 560 

Kreutzman  on  chloroform-oxygen,  27 

Krogius's  method  of  local  anesthesia 
in  circumcision,  514 

Labor*  hypnotism  and,  648 
Lachrymation,  effect  of   anesthesia  on, 

60 
Lactation,  effect  of  ether,  on,  191,  192 
Ladd   on   toxic    effects   of   etherization 

by  the  closed  method,  102 
Laewen  on  nerve-blocking,  511,  512,  519 
Lambotte    on    stovain    in    spinal    anal- 
gesia, 603 
Lamella  cocainae,  769 
Laminectomy,   intratracheal  insufflation 

indicated  in,  431 
Langgaard  on  chloral  chloroform,  876 
on  eueain  lactate  in  local  anesthesia, 
757 
Laparotomy,     anesthesia    during,     355, 
356,  374,  375 
eoloaie  ether  anesthesia     contra-indi- 
cated in,  457 
post-anesthetic   abdominal   distention 

after,   115 
shock  in,  389 

under  local  anesthesia,  518 
under  rectal  etherization,  435 
under  spinal  analgesia,  595 
Laryngectomy,  intratracheal  anesthesia 

indicated  in,  432 
Laryngology,    ethyl    aminobenzoate    in, 
737 
local  anesthesia  in,  489 
Laryngoscope,  Jackson's  direct,  428 
Larynx,     cocainization    of,    for    intra- 
tracheal insufflation,  427 
Larynx  operations  under  colonic  ether 
anesthesia,  454,  457 
under  local  anesthesia,  502 
under  spinal  analgesia,  587 
Lassar-Cohn 's     method     of     purifying 

ether,  868 
Latham's   measures   for    shock   preven- 
tion, 403,  404 
Laudanon,  769 

Laughing  gas.     See  Nitrous  oxid 
Lavosier,  oxygen  studied  by,  893 
Laweh    on    novocain   bicarbonate    solu- 
tions, 786 
on  post-operative  pneumonia,  70 
on  warmed  ether  vapor,  228 
Lawrie's  statistics  on  chloroform,  852, 

853 
Lead   dioxid  in  purification   of   chloro- 
form, 879 
Lecithin  in  case  of  acute  mania,  669 
Leduc  and  Eouxeau,  experiments  of,  on 
electric  anesthesia,  628 
on  electric  resuscitation,  637 
Leedham-Green 's    use    of    spinal    anal- 
gesia, 587 


Leg,  amputation  of,  shock  in,  403 
cross-section  of,  above  ankle,  509 

Legal  status  of  physician,  678 

Leggett  's  apparatus  for  colonic  ether 
anesthesia,  437,  441,  442,  444 

Legislation,   medical,  early,   677,  678 

Legrand  on  eucain-B,  754,  756 

Leichter  salzdther,  250.  See  also  Ethyl 
chlorid 

Lennander  on  lack  of  sensation  in  pel- 
vic viscera,  488,  516,  517,  518 

Leopold  on  spinal  analgesia,  569,  570 

Lerda  on  local  anesthesia  in  reduction 
of  fractures,  508 

Letargin,  769 

Letheon,  16,  536,  769 

Leukemia,  sequestration  anesthesia 
contra-indicated  in^  470 

Levi  on  use  of  carbon  dioxid  with  anes- 
thetics, 99 

Lewis  pendulum  swing,  246,  393-396. 

Liability  of  physician,   680-687 
of  specialist,  684,  685 

Liebermann,  tropacocain  prepared  by, 
832 

Liebig,    chloral    chloroform    discovered 
by,  876 
discovery  of  chloroform  by,  871,  872 
investigations     of,     on     etherization, 
862 

Liebreich  's  method  of  preparing  chloral 
chloroform,  876 

Light,    effect    of,    on    chloroform,    290, 
295,  296,  883-889 
on  ethyl  chlorid,  256 
in  adenoid  and  tonsil  operations,  344 

Light  anesthesia,   shock  during,  389 

Light  chloroform  anesthesia,  306 

Light  sleep,  hypnotic,  654 

Ligueu's  apparatus  for  colonic  ether 
anesthesia,  442 

Lillie's  theory  of  anesthesia,  50-55 

Lime  as  preservative  of  chloroform,  291 

Lime  salts  in  the  blood,  sequestration 
anesthesia  contra-indicated  in, 
470 

Lingual  nerve,  anesthetization  of,  550, 
551 

Linhart  's  A.  C.  mixture,  769 

Linhart's  C.  E.  mixture,  769 

Lip  excision  under  local  anesthesia,  498 

Lipoid  solubility  theory  of  anesthesia, 
37-40,  46,  47,  48 

Lipoidemia,  47,  48 

Lipoids,  role  of,  in  anesthesia,  43,  44 

Lipomata,  removal  of,  under  local  anes- 
thesia, 495 
under  spinal  analgesia,  625 

Liquid  air,  in  dental  anesthesia,  537 
preparation  of  oxyge;i  from,  894 

Liquor  angestheticus,  770 

Liquor  anodynus  Hoffmani,  859 

Liquor  Hollandicus.  See  Ethylene 
chlorid 

Liver,  diseases  of,  sequestration  anes- 
thesia in,  473 


924 


INDEX 


Liver,  effect  of  chloroform  on,  304 
effect  of  ether  on,  189,  190,  198 

effect  of  shock  on,  385 

excision  of,  518 

fatty,  acidosis  in,  415 

fatty   degeneration   of,   following  re- 
peated administrations   of   ethyl 
chlorid',  265 
Liver  operations,  shock  in,  403 
Local  anes-ether,  856 
Local  anesthesia,  476-523 

after-treatment  in,  488 

as  applied   in  dentistry,  535-553 
cocain,  538-543 
cold,  537 

ethyl  chlorid,  537,  538 
hypodermic  method,  536,  537 
history,  535,  536 
technique  of   injection,   543-553 

circumcision  under,  513,  514 

combined    with    general     anesthesia, 
488 

general  preparation  and  technique  in, 
486-488 

history  of,  476-488 

in  diseases  of  the  lungs,  330 

in  eye  surgery,  500,  501 

in  gastro-enterostomy,  356 

in  Graves'  disease,  353,  354 

in  gynecology,  516 

in  heart  disease,  329 

in  inguinal  hernia,  519-623 

in  larynx  surgery,  502 

in  neck  surgery,  501,  502 

in  rectum  surgery,  514,   515,   517 

in  surgery  of  genito-urinary  system, 
512 

in   surgery   of   head    and   neck,   496, 
497 

in  thyroid  operations,  502-505 

in  tracheotomy,  502 

in  treatment  of  nose  and  tonsils,  499, 
500 

indications  and  scope  of,  484,  485 
-    infiltration  method  of,  489 

mental  iniiuence  in,  651,  652 

methods  of,  488-493 

mortality  in,  478,  486 

of  abdomen,  516-519 

of  ear,  498,  499 

of  extremities,  506-512 

of  skin,  493-496 

of  thorax  and  breast,  505,  506 

preliminary  use  of  morphin  in,  370 

regional  method  of,  490 

solutions    for,    in    goiter    operations, 
503,  504 

special  application  of,  493-523 

statistics  for,  842,  843,  844,  855 

surface   application   method   of,   488, 
489 

syringes    and    solution    bottles    for, 
481 

through  physiological   action  of  spe- 
cial drugs,  477,  478 

versus  general  anesthesia,  485,  486 


Local   anesthetics;   relation    of   general 

anesthetics  to,  48 
Locasemin,  770 
Loco-dolor,    250,    537,    770.      See    also 

Ethyl  chlorid 
Locomotor  ataxia,  anesthetic  treatment 

for,  667 
Loeffler     on    method    of    anesthetizing 

dental  pulp,  552 
London   Medical   and   Chirurgical  mix- 
tures,  770 
Long,  Crawford  W.,  8-10,  19,  177 
Lotheissen,  experiments  of,  on  elimina- 
tion of  ethyl  chlorid,  263-265 
Lotheissen 's    method    of    administering 

ethyl    chlorid    and    oxygen,    278, 

279 
Ludwig's    angina   under    colonic    ether 

anesthesia,  454 
Lues,  spinal  analgesia  contra-indicated 

in,  587 
Luke  and  Ross,  statistics  of,  on  nitrous 

oxid  and  ethyl  chlorid,  854 
LuUius,  Raymundus,  858 
Lumbar  anesthesia  by  magnesium  salts, 

770,  771 
by  tropacocain,  836,  837 
Erhardt's  solutions  for,  735 
use  of  cocain  arabinate  in,  726 
use   of    tropacocain   hydrochlorid   in, 

833 
Lumbar  pressure,  measurement  of,  583 
Lumbar  puncture,  early  experiments  in, 

557,  563 
Lumbard's  elastic  mask  holder,  202 
Lumbard's  glass  nasal  tubes,  229 
Lumbard's  rubber   ether  blanket,   202 
Lungs,   aeration  of,   during  anesthesia, 

376 
concomitant     affections     of,     spinal 

analgesia      contra-indicated      in, 

587 
diseases  of,   anesthesia  in,   329,  330 

ether  contra-indicated  in,  248 
effect  of  ethyl  chlorid  on,  258 
effect  of  moisture  contents  of  air  on, 

77,  78 
effect  of  nitrous  oxid  on,  128 
excretion    of    ethyl    chlorid    through, 

264 
Lung  abscess,  drainage  of,  under  local 

anesthesia,  505 
Lung      complications,      post-anesthetic, 

abolition  of,  by  rebreathing,  113, 

115 
Lung    cyst    removal    under    medullary 

analgesia,  575 
Lung   lesions,   colonic   ether   anesthesia 

indicated  in  case  of,  457 
Lungmotor    for   induction   of   artificial 

respiration,  399 
Lusk,  564,  621 

on  paralyses  due  to  spinal  analgesic 

agents,  584,  585 
on  spinal  puncture,  605-607 
Lycoperdon  proteus.     See  Puff-ball 


INDEX 


925 


Lyman  on  puflf-ball,  804 

Lymphatism,  331-337.     See  also  Status 

lymphaticus 
Lymph-nodes,      cervical,      removal      of, 

under  local  anesthesia,  498 

MacFarlane,  J.  P.,  and  Co.,  on  chloro- 
form    prepared     from     acetone, 
882 
Magnesium  salts,  735,  770-772 
Maier  's       Eadikal-anasthetikum.       See 

Eadikal-anasthetikum  Maier 
Malartic  on  spinal  analgesia  in  obstet- 
rics, 593 
Malherbe's    method    of    administering 

ethyl  chlorid,  272 
Malpractice,  682-684 

criminal,    686 
Management   of   ordinary   cases,   after- 
treatment  in,  378,  379 
preliminary  treatment  in,  364-374 
treatment  during  anesthesia  in,  374- 
378 
Management     of     unusual     cases,    379- 
414,  415 
idiosyncratic  difficulties  in,  382 
muscular  difficulties  in,  381 
nervous  difficulties  in,  381 
post-anesthetic  toxemia  in,  382,  413- 

415 
respiratory  difficulties  in,  380,  381 
shock  in,  383-413 
Mandibular  foramen,  location  of,  549 
Mandibular    nerve,    anesthetization    of, 

551 
Mandragora,  2,  282,  477 
Mania,  acute,  anesthetic  treatment  for, 

668-670 
Mannin,  772 

Manometer,     safety    valve    water,    for 
colonic     ether     anesthesia,     444, 
446,   451 
Manual  means  of  artificial  respiration, 

393 
Marcille    on   ether   irrigation   of   abdo- 
men, 672 
Martin,  E.  D.,  on  cocain  in  spinal  anal- 
gesia, 600 
Martindale's  mixture,  689,  772 
Martmeyer,  ether  introduced  into  com- 
merce by,  859 
Marx    on    spinal    analgesia,    560,    593, 

600 
Mask,  Boothby  and  Cotton,  for  nitrous 
oxid-oxygen   anesthesia,    166 
Ferguson,  203 

Gwathmey-Woolsey,  for  nitrous  oxid- 
oxygen  anesthesia,  172 
Meltzer  's,    for    artificial    respiration, 

400 
usual  ether,  202 
Yangauer,  203 
Massage,    cardiac.      See   Cardiac   Mas- 
sage 
Masseter  muscles,  contraction  of,  under 
ethyl  chlorid,  261,  262 


Masson's  method  of  purifying  chloro- 
form, 880 

Mastoid  operation,   anesthesia  in,  339 
colonic  ether,  454 
local,  499 

Matas,    afjparatus    of,    for    hypodermic 
injection,  484 
on  cocain,  478,  482,  490,  497 
on  limitations  in  use  of  spinal  anal- 
gesia, 586 

Mathews-Brown  theory  of  anesthesia, 
42-44 

Mayos'  administration  of  ether,  203- 
205 

Mayos'  stripping  procedure  under  local 
anesthesia,  511 

Mayow,  oxygen  prepared  by,  893 

Maxillae,  operations  on,  chloroform  in- 
dicated for,  310 

McKesson,  blood-pressure  apparatus  of, 
409,  411 
blood-pressure  chart  of,  412 
method    of,    for    anticipating    shock, 
410-413 

Measure  dropper  for  ethyl  chlorid,  256 

Mechanical  causes  of  psychic  shock, 
384 

Medical  Pneumatic  Institute,  organiza- 
tion of,  4 

Medical  treatment  preliminary  to  anes- 
thesia, 26,  370-378 

' '  Medicated  Vapors, ' '  by  Humphrey,  7 

Medico-legal  status  of  the  anesthetist, 
675-687 

Medullary  anesthesia  by  tropacocain 
hydrochlorid,  834 

Meissner  on  novocain  in  spinal  anal- 
gesia, 604 

Meltzer,    devices   of,   for   artificial   res- 
piration, 399-401 
experiments      of,      with     magnesium 

salts,  770-772 
method  of,  for  ether  vapor  adminis- 
tration, 238 

Meltzer  apparatus  for  intratracheal  in- 
sufflation, 417 

Meltzer  pharyngeal  tube,  400 

Meltzer  and  Auer,  experiments  of,  with 
intratracheal  insufflation,  416- 
419 

Meningism  after  stovain  anesthesia, 
583 

Menstrual  period,  anesthesia  during, 
355 

Mental  condition,  influence  of,  on  hyp- 
notism, 656 

Mental  depression,  fatal  effects  of, 
368 

Mental  foramen,  location  of,  551 

Mental  influence  in  anesthesia,  644-665 
hypnosis,  653-665 
hypnotism,  644-649 
suggestion,  649-653 

Mental  suggestion  in  adenoid  and  ton- 
sil operations,  341 
in  anesthetizing  children,  327 


926 


INDEX 


Menthol  as  preservative  of  chloroform, 
.    292 
petrolatum  and,  as  a  spray,  preceding 

adenoid    and    tonsil    operations, 

341 
Menthol  thymate,  772 
Mentholated  chloral,  723 
Menthophenol,  772 
Menthophenol    cocain,    772.      See    also 

Bonain 
Mentin's   method   of   purifying   chloro- 
form, 879 
Merck  on  soninoform,  819 
Mering  and  amylene  hydrate,  699 
von   Mering 's   mixture,   772.     See  also 

Dimethylacetal 
Mesenteric   glands,   enlargement   of,   in 

status  lymphaticus,  332 
Mesmerism,  2,  4 
Meta-amido-para-oxybenzoate  of  methyl. 

See  Orthoform-new 
Metacetone,  804 

MetEethyl,  772.     See  also  Meth-ethyl 
Metal  containers  for  ethyl  chlorid,  255, 

256 
Metaldehyd,  689 

Metallic  chlorids   in   chloroform,   285 
Meta-nitro-cocain,  688 
Metatarsals,     deep    injection     between, 

510 
Methaform,    711,    772,    773.      See    also 

Chloretone 
Methane,   773 

preparation  of  chloroform  from,  875 
Methene  chlorid,  777 
Methenyl     trichlorid,     281.       See     also 

Chloroform 
Methenyl-o-anisidin,  773 
Methenyl-p-phenetidin,  773 
Meth-ethyl,  537,  773 
Methoxycaffein,   773 
Methyl  acetylsalicylate,  773 
Methyl  alcohol,  773,  774 

in  chloroform,  285,  692 
Methyl  bromid,  774 
Methyl  chlorid,  774,  775 

combined     with     ethyl    bromid     and 

ethyl  chlorid   (somnoform),  276 
for  local  anesthesia  in  dentistry,  537 
presence    of,    in    ethyl    chlorid,    252, 

253 
Methyl  chlorid-alcohol,  775 
Methyl  chlorid-ether,   775 
Methyl     chloroform,     832.       See     also 

Trichlorethane 
Methyl  cinnamenylacrylate,  775 
Methyl  dichlorid,  775,  776 
Methyl  ether,  776 
Methyl  fluorid,  776 
Methyl     hydrate     or     hydroxid.       See 

Methyl  alcohol 
Methyl  iodid,  776 
Methyl  oxid,  776 
Methyl    salicylates    as    preservative    of 

chloroform,  292 
Methylacetyl,  689.     See  Acetone 


Methylal,  776,  777 

"Methylated"   alcohol,  ether  prepared 

from,  861,  862 
"Methylated"   chloroform,   873,  874 
* '  Methylated    spirit, ' '    preparation    of 

chloroform  from,  285,  873,  874 
Methylene,  777 
Methylene    bichlorid,     777.      See    also 

Narcotil 
Methylene  chlorid,  777,  778 
Methylene  dimethylate,  776,  777 
Methylene- dimethyl  ester,  776,  777 
Methylene  ether,  778 
Methylethyl,  778 
Methylic  ether,  861,  862 
Methylic-ethylic  ether,  778 
Methylium      bichloratum      Eichardson. 

See  Methylene  ether 
Methylium   oxyamidobenzoicum,  778 
Methylpropylcarbinolurethane,  763,  778 
Methyl-protocatechnique      aldehyd,      as 

preservative   of   chloroform,   292 
Meyer  on  anesthol,  276-278 

on  "M.  S.,"  779 
Meyer's  angesthol,  702-711 
Meyer's  tropacoeain  solution  for  spinal 

analgesia,  601 
Meyer- Overton     theory    of     anesthesia, 

37-40 
M.-H.-C.  anesthesia,  statistics  for,  843 
Michelson  on  spinal  analgesia,  564,  570, 

598 
Micturition,     involuntary,     in     nitrous 

oxid  anesthesia,  132 
Midy's  mixture,   778 
Milk,  prohibited  preceding  adenoid  and 

tonsil  operations,  340 
Miller  on  method  of  anesthetizing  den- 
tal pulp,  552 
statistics  of,  on  ethyl  chlorid,  850 
Milne,    open    method    of    administering 

ethyl  chlorid  advocated  by,  272 
Minor    surgery,   intravenous   anesthesia 

in,  492 
Mitchell,  James  F.,  on  local  anesthesia, 

476-523 
on  nerve  injuries,  558 
Mitchener  and  Hyndham,  on  magnesium 

sulphate,   771 
Mitscherlich  on  chloroform,  873 

theory  of,  of  manufacture  of  ether, 

862,  863 
Mohr    apparatus    for    rectification    of 

ether,  864 
Moisture,  effects  of,  on  anesthetics,  76- 

80 
Molars,    technique   of   periosteal   injec- 
tion      of      anesthetic      solution 

about,   545 
Molecular  solution.     See  "M.  S." 
Moles,    removal    of,    under    local    anes- 
thesia, 495 
Monobromethane,     738-748.       See    also 

Ethyl  bromid 
Monochlorethane,  748.     See  also  Ethyl 

chlorid 


INDEX 


927 


Monochlorethylene  chlorid,  750 
Mono-chlorethylidene  chlorid,   832 
Monochlorinated  dutch  liquid,  750 
Monochloro-ethylene    chlorid,    831,    832. 

See  Ethylene  chlorid 
Monochloromethane,     250.        See     also 

Ethyl  chlorid 
Mono-iodoethane,   748 
Moore-Eoaf    theory    of   anesthesia,    44- 

46 
Morel's    apparatus    for    colonic    ether 

anesthesia,  442 
Morphin,  463,  464,  465 

administration  of,   during  anesthesia 

in  status  lymphaticus,   334 
as  preservative  of  chloroform,  292 
contra-indications  to,  373 
doses  of,   372 

for  acid  intoxication,  414 

for  adenoid  and  tonsil  operations, 

341 
for    anesthol    administration,    277, 

705 
for   colonic   ether   anesthesia,   450, 

454 
for  ether  anesthesia,  207,  208 
for   ethyl   chlorid   anesthesia,    262, 

277 
for  intratracheal  anesthesia,  427 
for  local  anesthesia,  486 
for  nitrous  oxid-oxygeu  anesthesia, 

165 
for  oil-ether  colonic  anesthesia,  461 
for  spinal  analgesia,  558,  581,  592, 
612 
effect  of,  on  ether  elimination,   108 
in     administration      of     chloroform, 

314 
in  case  of  acute  mania,  669 
in  emergency  treatment,  363 
in  goiter,  354 

in  intravenous  anesthesia,   524,   533 
in  post-operative  treatment,  377 
in    preliminary    medication,    328-331, 

339,  369,  370,  371,  412,  847 
in  prevention  of  acapnia,  409 
in  rectal  cases,  355 
with  chloroform,   26 
Morphin-anesthol-ether  sequence,   209 
Morphin  hydrochlorid,  778,  779 
Morphin,  hyoscin,  and  cactin,  768.    See 

also  H.  M.  C. 
Morphin     injection     before     operation, 
482 
in  neuralgia,   478 
in  shock  prevention,  403 
Morphin    poisoning,    electric    resuscita- 
tion in,  643 
Morphin-scopolamin,    108,    811-817 
decrease      in      post-operative      pneu- 
monias under,  199 
prophylactic     use     of,      with     ethyl 
chlorid  anesthesia,  262,  263 
Morphin     sulphate     injection     in     local 

anesthesia,  486 
Morphinism,  chronic,   acidosis  in,  415 


Morson  on  effect  of  air  on  ebloroform, 

883 
Mortimer  on  chloroform,  414 

on  contra-indications  to  ether,  248 
Morton,    William   T.   G.,   11-14,    16,    17, 
18,   177 
first  demonstration  of  surgical  anes- 
thesia by,  13 
on  spinal  analgesia,  562 
cases  of,  574 
Morton  inhaler,  13,  14 
Morton's  "letheon,"  536 
Motor   paralysis   from   Esmarch   elastic 
bandage,  477 
in  venous  anesthesia,  492 
Mouth,   disinfection   of,  preliminary   to 
anesthesia,  364 
effect  of  shock  on,  385 
operations  on,  colonic  ether  indicated 
in,  457 
ether  for,  247 
intratracheal   insufflation   for,   431, 

432 
local  anesthesia  for,  497 
rectal  etherization  for,  435 
sequestration  anesthesia  for,  471 
with  Sutton's     colonic     anesthesia 
apparatus,  450 
Mouth-gag,  362 

Hewitt-Mason 's,       with       anesthetic 

tubes,  322 
in  artificial  respiration,  393 
in  epileptics,  331 
in  ethyl  chlorid  anesthesia,  274 
in  intratracheal  anesthesia,  427 
"M.  S.,"  704,  709,  710,  779 
Mucous  glands,  effect  of  anesthesia  on, 
60 
effect  of  warming  the  anesthetic  on, 
70 
Mucus,   secretion   of,   after   ether,    189, 

199 
Miiller,   on   use   of    oxygen   with    anes- 
thetics,  86-88 
theory  of,  of  anesthesia,  36,  37 
of    ethyl    chlorid    anesthesia,    260, 
261 
Mulzer,     experiments     of,     with     ether 

upon  the  blood,  186,  187 
Murphy  on  spinal  analgesia,  561,   586, 

604 
Muscular  changes  due  to  psychic  shock, 

385 
Muscular  flaccidity  in  overdose  of  ethyl 

chlorid,  261 
Muscular  phenomena  during  anesthesia, 

381,  385 
Muscular  relaxation  or  rigidity  in  ethyl 

chlorid  anesthesia,  263 
Muscular  system,  effects  of  anesthetics 
on,  59,  60 
effects  of  chloroform  on,  302,   303 
effects  of  ether  on,  189 
effects  of  ethyl  chlorid  on,  261 
effects  of  nitrous  oxid  on,  131 
Mylocal,  779  ' 


928 


INDEX 


Myocarditis,  sequestration  anesthesia 
contra-indicated   in,   473 

Myogram  traces  showing  muscle-nerve 
reaction,  629,   631-633 

"Nabolis,"  536 
Nalicin,  779 
Naphtha,   860 
Naphthalene,-  714 

Nasal  operations  under  rectal  etheriza- 
tion, 435 
Narcoform,  779 
Narcophin,   780 
Narcosin,  780 
Narcosis,  distinguished  from  anesthesia, 

50 
Narcotil,  780 
"  Narkose-gemisch "      Dr.      Hirschlaff, 

780 
Nasal  anesthesia  with  nitrous  oxid-oxy- 
gen,  in  aural  surgery,  173 
in  obstetrics,  173 
Nasal    catarrh,    use    of    orthoform-new 

in,    789 
Nasal  inhaler,  Teter,  155,  156 
Nasopharyngeal  tubes  for  nitrous  oxid 

and  oxygen,  Teter 's,  157 
Natural  gas,  preparation  of  chloroform 
from,  875 
preparation  of  ether  from,  862 
Nausea   after  colonic  ether   anesthesia, 
438,  458,  464 
after   ethyl    chlorid    anesthesia,    264, 

338 
after  use  of  nitrous  oxid,  132 
due  to  cocain,  539 
in    spinal    analgesia,    577,    582,    583, 

595 
post-anesthetic,  113 

effect  of  oil  of  bitter  orange  peel 

on,  94 
effect    of   warming   the   agent    on, 

70 
treatment  for,   379 
preliminary  medication  in,  373 
prevention  of,  during  anesthesia,  374 
Nealpon,   780 

Neck,  operations  on,  colonic  ether  anes- 
thesia indicated  in,  457 
intratracheal  insufflation   indicated 

in,  431 
under   local   anesthesia,    501-505 
under  spinal  analgesia,  597 
swelling   or   engorgement   of,   nitrous 
oxid  contra-indicated  in,  338 
Necrosis,  due  to  prolonged  freezing  in 

dental   anesthesia,  537 
Nef's   bivalent   carbon   hypothesis,    42, 

Negroes,  importance  of  psychic  influ- 
ences in  anesthetizing,  651 

Neidle's  experiments  on  heat  generated 
by  chloroform-ether  mixture, 
706-710 

Nephritis,   anesthesia  in,   374 
dosage  of  hyoscin  in,  815 


Nephritis,    preliminary    medication    by 
morphin,      contra-indicated      in, 
373 
spinal  analgesia  in,  580,  587 
Nephropectomy  under  spinal  analgesia, 

560 
Nephrotomy   under  colonic  ether  anes- 
thesia, 454 
Nerve   block    in    local   anesthesia,    497, 
498,  513 
of  arm,  507 
of  face,  497 
in  skin  grafting,  511 
Nerve   centers,   effect   of   aliphatic  hy- 
drocarbons on,  689 
specific    action    of    nitrous    oxid    on, 
125-127 
Nerve  corpuscles  in  anesthesia,  33 
Nerve  fibers  in  anesthesia,  33 
Nerve    tissue,    effect    of    ethyl    chlorid 

on,  261 
Nerve  trunk  injection,  solution  for,  480 
Nervocidin,  780,  781 
Nervous  patients,   choice  of   anesthetic 

in,  330 
Nervous  phenomena  during  anesthesia, 

381 
Nervous    system,    anesthetic    treatment 
for   extreme   irritability  of,   667' 
effect  of  anesthesia  on,  61,  62 
effect  of  chloroform  on,  302 
effect  of  ether  on,  188 
effect  of  ethyl  chlorid  on,  260,  261 
effect  of  nitrous  oxid  on,  131 
post-operative  effects  of  spinal  anal- 
gesia  on,    582 
Nessler  's    reagent,    in    testing    chloro- 
form, 890 
Netter  on  magnesium  salts,  771 
Neudorfer   on   chloroform  and   oxygen, 

26 
Neuralgia,  chloral-menthol  in,  723 
differentiation  of,   from  neuritis,  by 
ethyl  chlorid,  670 
from    visceral    diseases,    by    ethyl 
chlorid,  671 
ethyl  chlorid  in  treatment  of,  670 
injection  of  morphin  in,  478 
Neurasthenia,  use  of  hedonal  in,  764 
Neurocain,  781 

Neuroglia,  in  anesthesia,  35,  36 
Neuroregional    anesthesia    in    inguinal 
hernia,   519-523 
local  method  of,  478 
of  extremities,  506 
Neurorrhaphy  under  colonic  ether  anes- 
thesia, 454 
Neurotic  patients,   preliminary  medica- 
tion in  anesthetizing,   371 
under  spinal  analgesia,  591 
Nicloux  on  ether  elimination,  196 

on  the  passage  of  ether  from  mother 
to  fetus,  191 
Niemann 's  discovery  of  cocain,  555 
Nirvanin,  540,  781,  782 
in  spinal  analgesia,  563,  599 


INDEX 


929 


Niter  in  preliminary  treatment  of  kid- 
neys, 364 
"Nitric  "ether,"    749 
Nitrobenzene  as  preservative  of  chloro- 
form, 292 
Nitrogen,   782,  78;] 

Nitrogen  monoxid.      See  Nitrous  oxid 
Nitrogen  protoxid.     See  Nitrous  oxid 
Nitroglycerin  injection   in   spinal   anal- 
gesia, 581,  592,  612,  625 
"Nitrous  ether,"  749 
Nitrous  oxid,  692,  783 

administration  of,    136-175 
alone,  137 

apparatus  for,  136 

dangers  of,  136,  137 

Guedel   aj^paratus   for,    138,    139, 

140 
precautions  in,  137-139 
as  a   sequence   to   ether,    141,    142, 

143 
by  intratracheal  insufflation,  429 
rebreathing  in,   105-144 
with  air,  136,  137,  142 

advantages  of  oxygen  over,   143, 

144 
in  unknown   quantities,   140,   141 
in  definite  amounts,  141 
safety  of,  325 
with  chloroform-ether,   142,  143 
with    oxygen.      See    Nitrous    oxid 
and  oxygen 
after-effects  of,  135 
analysis  of,  122 
causes  of   death  from,   132 
chemical  properties  of,  121 
comparison  of,  with  other  agents,  135 
contra-indicated,  in  ophthalmic  cases, 

338       . 
danger  of  shock  with,  388 
deoxygenation  or  asphyxiation  theory 

of  action  of,  124,  125 
discovery  of,  4,  10 
early  use  of,   by  Humphrey  Davy,   5 

in  dentistry,  118,  119 
effect  of,  on  blood  pressure,  59 
on  circulatory   system,   128-131 
on     glandular     system    and     other 

structures,  131,  132 
on  muscular   system,   131 
on  nervous  system,  131 
on  respiratory  system,  127,  128 
elimination  of,  from  the  blood,   134, 

135 
ethyl  chlorid  and,  279 
ethyl   chlorid  compared  to,   266,   267, 

849 
for   anesthetizing  children,   327 
for  short  operations,  338 
history  of  use  of,  118-120 
hyperoxygenation    theory    of    action 

of,   123,   124 
impurities  of,  121,  122 
in  adenoid  and  tonsil  cases,  340 
in  convulsions  from  poisoning,  667 
in  dentistry,  11,  24,  537 


Nitrous  oxid   in  fracture   reduction   un- 
der local  anesthesia,  508,  509 

in  gastro-enterostomy,  356 

in  goiter,  353,  354 

in  insanity  cases,  381 

in  local  liucsthesia  of  abdouion,  518 

in  nervous  patients,  330 

in    2:)aracentesis    of    membrana    tym- 
pani,  339 

indications      and      contra-imiications 
for,  135,  136 

insusceptibility  to,  832 

introduction  of,  into  England,  24 

liquid,  120 

in  dental  anesthesia,  537 

manufacture  of,  121 

method  of  heating,  136 

overdose   of,    symptoms   of,   167 

physical  properties  of,  120,  121 

preliminary  use  of,  388 

special  physiology  of,  123-135 

specific  action  of,  on  brain  cells,  125 

stages  of   anesthesia  with,   132-134 

standard  of  purity  of,  122,  123 

statistics  for,  843,  844,  855 

Stockman  and,  5 

use  of  scopolamin-morphin  with,  816 

wdth  air  and  ether,  statistics  of,  856 

with  ether,  25 

with  ethylene  chlorid,  749 
Nitrous   oxid   and    oxygen,    24,    80,    81, 
119,  120,  143-175 

administration  of,  Davis'  method  of, 
151 
endopharyngeally,  159,  160 
Gatch's  method  of,  144-151 

Gwathmey-Woolsey     method     of, 

171-175 
Hewitt's  method  of,  151-153 
Teter's  method   of,    153-159 
with  oxygen,  in  definite  quantities, 
Boothby  and.  Cotton  method  of, 
160-170 
with    oxygen   in   indefinite    quanti- 
ties, 144 
with  rebreathing,  104-144 

advantages  of,  143,  144 

combined   with  ether,   164,   165,   167, 
168,  172 
statistics  for,  855,  857 

combined  Avith   ethyl  chlorid,   325 

combined  with  warm  ether,  325 

contra-indications  to,  328 
brain  operations,  354 

effect  of  warming  on,  64-66 

effect  of,  on  heart  action,  670 

for  endotracheal  work,   173 

for     patients     between     19     and  50, 
328 

in  anemic  convulsions,  667 

in  cancer,   330 

in   curettage,   355 

in  diabetes,  330 

in   diagnosis,    667 

in  kidney  diseases,  330 

in  obstetrical  cases,  355 


930 


INDEX 


Nitrous    oxid    and    oxygen    in    paracen- 
tesis of  the  pericardium,  329 
in  rectal  cases,  355 
in  respiratory  diseases,  330 
in  short  operations,  338 
in   tuberculosis,   329 
premedication  in,  165 
safety  of,  325 

statistics  for,  843,  844-847,  855,  857 
therapeutic  uses  of,  670 
use    of,    in    Gatch's    apparatus,    104, 
107 
Nitrous  oxid  anesthesia,  404 
exhaustion  under,  405 
Gatch's  method  of,  103-115 
acapnia  in,  112 
basis  of  technique  of,  105 
clinical  results  of,  108,  109 
fatalities  from,  110 
hypereapnia  in.   111 
in  cardiac  cases,  111 
in  long  operations,  illustrative  cases 

of,   109 
maintenance  of  ether  balance  in,  106 
Nitrous    oxid-anesthol,     statistics     for, 

843 
Nitrous    oxid-ether    sequence,     218-320, 
240,   325 
followed  by  ether,  325 
followed    by    ether    and    chloroform, 

325 
in   genito-urinary   operations,   355 
in  laparotomy,  355,  356 
in  mastoid  operations,  339 
inhalers   for,   218-221 
introduced  by  Clover,  177 
statistics  for,  843,  848,  855,  857 
technique  of,  221 
Nitrous     oxid-ether-anesthol,     sequence, 

statistics  for,  843,  855 
Nitrous  oxid-ether-chloroform  sequence, 
223-224 
statistics  for,  843,  851,  852,  855 
Nitrous      oxid-ether      vapor      sequence, 

diagrammatic  sketch  of,  245 
Nitrous     oxid-ethyl     chlorid-ether      se- 
quence, 325 
Nitrous      oxid-oxygen-ether      sequence, 

325 
Nitrous  oxid-oxygen-ether-chlorof  orm  se- 
quence, statistics  for,  855 
Nopain,  783 
Nor-cocain,  783 
Northrop    on    oxygen    and    chloroform, 

27 
Nose,  care  of,  preliminary  to  anesthesia, 
364 
closure  of  alee  of,  during  anesthesia, 

389 
operations  on,  alypin  in,  693 
ether  for,  247' 

eucain   lactate  solution   for,   758 
under  local  anesthesia,  497 
treatment  of,  under  local  anesthesia, 
499,  500 
Novadrin,  783 


Novocain,  691,  692,  783-786 
atoxyl  and,  818 
in   anoci-association,   370 
in  anesthesia  of  scalp,  497 
in  gastroenterostomy,  356 
in  goiter  operations,  354 
in  hypodermic  tablets,  604 
in  local  anesthesia,  478,  482,  483 

in  dentistry,  540,  541 
in  oil-ether  colonic  anesthesia,  463 
in    spinal    analgesia,    563,    571,    576, 

599,  603,  604 
in  venous  anesthesia,  490 
statistics  for,   842 
Novocain,  adrenalin,  and  sodium  bicar- 
bonate, 786 
Novocain  and  epinephrin,  statistics  for, 

841 
Novocain  bicarbonate  solutions,  786 
Novocain    infiltration    in    general    anes- 
thesia, 485 
in  venous  anesthesia,  491 
Novocain    injection    along    line    of    in- 
cision in  shock  prevention,  406 
Novocain  nitrate,  786,  787 
Novocain  solutions,  482,  483 

for  arterial  anesthesia,  492 
Novocain  tablets,  818 
Novocain-adrenalin     for     dental     anes- 
thesia, 540-542 
Novocain-suprarenin    injection    of    Gas- 

serian  ganglion,  498 
Novocain-suprarenin    solution,   787 
in   anesthesia  for  fractured  clavicle, 
506 
of  urethra  and  bladder,  512 
in   removal   of   cervical   lymph-nodes, 

498 
in  thyroids  operations,   505 
Novocain-suprarenin  tablets,  787 
Novoconephrin,   787 
Novo-dentsesthin,   787 
Novorenal,  787 

Novorobiol,  808.     See  also  Eobiol 
Nunneley,  T.,   713,   717,   719,   720,   738, 

837 
Nussbaum,    779 
Nussbaum's  mixture,  689,  787 
Nux    vomica,    tincture    of,    in    dietetic 
shock,  387 

Obalgo,  788 

Oberst's    regionary    anesthesia,    anesin 

in,  711 
Obese    patients,    chloroform    indicated 
for,  310 
choice  of  anesthetic  in,  329 
Obstetrics,  anesthesia  in,  355 

chloroform  anesthesia  in,  20-22,  310, 

368 
ethyl  chlorid  anesthesia  in,  266,  268 
hyoscin-morphin  mixture  in,   768 
hypnotism  and,  647,  648 
nitrous     oxid-oxygen     anesthesia     in, 

173 
Otis  mixture  in,  798 


INDEX 


931 


Obstetrics,     scopolamin-morphin     injec- 
tions in,  813,  815,  816 
spinal    analgesia    in,    560,    587,    593, 

594 
Townley's  anodyne  mixture  in,  831 
Obtundo,  788 

Occupation  and  surgical  shock,  384 
Octane,  788 
Odiot,  788 
Odor,   anesthetic,    elimination    of,     93, 

207,  208 
Offergeld  on  effect   of   ether   vapor  en 

the  lungs,  101 
Offergeld   and   Miiller,    experiments   of, 

with  animals,  335,   336 
Ohio  mojiovalve,   158-16.0 
Ohio  small  nitrous  oxid  inhaler,  159 
Oil  absinthium,  788 

Oil  of  bitter  orange  peel,  use  of,  pre- 
ceding anesthesia,  60,  92-96 
in  anesthol-ether  sequence,  847 
in  children,  327 
in    chloroform    administration,     313, 

316 
in     chloroform-ether     sequence,     207, 

847 
in  circumcision,  355 
physiological  basis  of,   95,   96 
Oil    of    bitter     orange     peel-ether    se- 
quence, 240 
statistics  for,  843,  852,  855 
"Oil  of  wine,"  864 
Oil  wormwood,   788 
Oil-ether  colonic  anesthesia,  458-466 
administration  of,  461 
animal  experimentation  with,  458-460 
apparatus  for,  460 
cases  of,  463-466 
history  of,  458 

oil-ether  mixture  for,  461,  463 
physiology  of,  462,  463 
preliminary     preparation     for,     460- 
463 
Old  age.     See  Aged 
Olefiant  gas,  736 
Olive  oil,  463 

administration  of,  during  anesthesia, 

376,   379 
in  case  of  acute  mania,  670 
in    preliminary    medication    for    oil- 
ether  colonic  anesthesia,  461 
Oliver   and   Garrett,   on   hyperoxygena- 
tion  theory  of  nitrous  oxid,  123, 
124 
Omnopon,  798-800.     See  also  Pantopon 
Open   method,   administration   of   ethyl 
chlorid  by,  272 
effects  of,  on  lungs,  101,  102 
use  of,  in  heart  disease,  329 
Ophthalmology,    alypin   in,   693 
chloroform  in,  338 
enophthalmin  as  antiseptic  in,  735 
ethylene  chlorid  in,  749 
eucain-A  in,  754 
eucain  lactate  solution  for,  758 
local  anesthesia  in,  489 


Ophthalmology,  novocain  in,  784 

tropacocain  hydrochlorid  in,  833 
O-phthaloyl-bis-methylecgonin,  788 
Opiopon,  788 

Opisthotonos,  due  to  ethyl  chlorid,  261 
Opium,  deodorized  tincture  of,  in  'post- 
operative  vomiting,   379 
preliminary  use  of,  653 
Opium    poisoning,    insufflation    of    pure 

air  or  air  and  oxygen  in,  432 
Opon,  788 

Oppenheimer 's  anaestiform,  710 
Opposition    to    anesthesia,    theological, 

21 
Opsonic  index,  restoration  of,  by  olive 

oil  administration,  376 
Orange,  peel.     See  Oil  of  bitter  orange 

peel 
Orchidopexy  under  colonic  ether   anes- 
thesia, 454 
Ormsby  's  statistics,    854 
Orndorff  and  Jessel,  on  preparation  of 

chloroform  from  acetone,  874 
Ortho-chlor-cocain,  688 
Orthoform,  699,  737,  788 

in  spinal  analgesia,  563 
Orthoform-new,   788-797 

in  spinal  analgesia,  599 
Orthoform-new   hydrochlorid,    797 
Orthonal,   797,   798 

Orthopnea,     colonic     ether     anesthesia 

contra-indicated  in   case   of,  457 

Osgood  on  toxic  effects  of  etherization 

by  the  closed  method,  102 
Osmotic  concentration   of  the  blood  in 

anesthesia,  45 
Osteopaths,   675 
Osterhout,  experiments  of,  40 
Otis  mixture,  798 
Otte  on  after-effects  of  ether,  199 
Ouabain,   798 

Ovary  operations,  shock  in,  403 
Over-anesthesia,  371,  386,  413 
Overdose,  402,  464,  465 
in  anesthetic  shock,  388 
in  anesthol  anesthesia,  277 
in  colonic  ether  anesthesia,  439,  452 
in  ether  narcosis,  195 
in  ethyl  chlorid  anesthesia,  263 
in  nitrous  oxid  anesthesia,  134 
in    oil-ether    colonic    anesthesia,    462, 

463 
in  spinal  analgesia,  597 
of  chloroform,  305,  308 
Overdose  stage  in  anesthesia,  381 
Overton.     See  Meyer-Overton 
Oxid  of  ethyl,  178 

Oxygen,   air   and,   insufflation   of,   as   a 
method   of   artificial   respiration, 
432 
as  an  anesthetic,  798 
as      preventive      of      post-anesthetic 

shock,  376 
as  vehicle   for  ether  vapor  in  rectal 
anesthesia,    441,    442,    452,    455, 
456 


932 


INDEX 


Oxygen,     combination     of,     with     anes- 
thetic agent,  80-89 
experiments  on,  82-86 
discovery  of,  4 
effect  of,  on  intestines,  114 
on  veins  and  arteries,  114 
ethyl  chlorid  and,  278,  279 
history  of,  893 
impurities  in,   894 

in  adenoid  and  tonsil  operations,  343 
in    chloroform    administration,     294, 

295,  314,  317 
increase  of,  in  shock  prevention,  403 
intestinal  absorption  of,  434 
intra-abdominal  administration  of,  in 
connection    with    anesthesia,    89- 
92 
methods     of     manufacturing     medi- 
cinal, 893,  894 
nitrous  oxid  and.     See  Nitrous  oxid 

and  oxygen 
purity  of  commercial   medicinal,   895 
standards  of  purity  for,  895 
supply    of,    essential    in    all    nitrous 

oxid  operations,  338 
with   carbon   dioxid  in   treatment   of 

acapnia,  409 
with    chloroform    by    Harcourt  's    in- 
haler, 321 
' '  Oxygen    enemata ' '    in    colonic    ether 

anesthesia,  453 
Oxygen-ether   mixture   in    colonic    anes- 
thesia, 444,  446 
Oxygen-ether  vapor,   administration  of, 
239,  240 
in  mastoid  operation,  339 
Oxysparteinum  hydrochlorid,  798 
Oxyuris    vermicularis,    use    of    guaiasa- 
nol  in,  763 

"Paid  anesthetist  system,"  676 
Pain,  abdominal,  in  colonic  ether  anes- 
thesia, 435_,  436,  455 
acute,  anesthetic  treatment  for,  666, 

667 
in  spinal  analgesia,  578 
localization    of,    with    ethyl    chlorid, 

671 
post-operative,   effect   of   preliminary 
medication  on,  371 
gas,  prevention  of,  405,  406 
in  local  anesthesia,  483 
Painless    surgery,    first    demonstration 

of,  by  Morton,  12 
Pallor  due  to  shock,  385 

in      administration      of      chloroform, 

308,  309,  313,  315 
in  chloroform  anesthesia,  389 
in  overdose  of  ethyl  chlorid,  261 
in  spinal  analgesia,  581,  582 
Panacea  vitrioli,  859 
Panhysterectomy     under     spinal     anal- 
gesia, 581 
Pantopon,    798-800 

preliminary      medication      with,      in 
ether  narcosis,   208 


Pantopon-scopolamin   anesthesia,   817 

Papilloma  of  neck,  operation  on,  under 
spinal  analgesia,   625 

Para-amidobenzoic  acid  ethyl  ester,  801 

Paracentesis     of     membrana     tympani, 
anesthesia  in,  339 
of  pericardium,   choice  of   anesthetic 

in,  329 
under  local  anesthesia,  499 

Paraffin  in  purification  of  chloroform, 
879 

Paraldehyd,  689,  800,  801 

in  intravenous  anesthesia,  533 
in     preliminary     medication     in     oil- 
ether  anesthesia,  461 

Paralysis    due    to    aromatic    hydrocar- 
bons, 689 
due  to  spinal  analgesic  agents,  584 

Paramidobenzoic  acid  ethyl  ester,  737, 
738 

Paranephrin,  801 

Paranephrin-cocain  mixture,  801 

Paranephrin-cocain-subcutin,   801 

Paranephrin-novo-subcutin,    801 

Para  -  oxy  -  meta  -  methoxyallyl-benzene, 
759 

Para-phenol  sulphonate  of  ansesthesin, 
829 

Para-phenol  sulphonic  acid  of  para- 
amidobenzoic  acid  ethyl  ether, 
829 

Pareses,  motor,  in  spinal  analgesia,  582, 
583 

Parotid  tumor  removal  under  colonic 
ether  anesthesia,  454 

Parturition,  use  of  ethyl  chlorid  in, 
266.     See  also  Obstetrics 

Passy  on  odorous  power  of  various  sub- 
stances, 93,  94,  889 

Pasteurization  in  Babcock's  diffusible 
solution  for  spinal  analgesia,  605 

Pate  de  vido,  801 

Patterson  on  spinal  analgesia,  577,  581 

Patton's  "Anesthesia  and  Anes- 
thetics," 11,  16 

Pelvic  cellulitis  case  under  oil-ether 
colonic  anesthesia,  463 

Pelvic  operations  under  spinal  anal- 
gesia, 586,  597 

Penis,  effect  of  shock  on,  386 

Pental,  698,  801,  802 
statistics  for,  853 

Pentan-2-ol-urethane,    763 

Pentane,  802 

Pentene,  697.     See  also  Amylene 

Pentylene.     See  Hydramyl 

Perchlorethane  in  chloroform  decompo- 
sition, 295 

Perchlorethylene  in  chloroform  de- 
composition, 295 

Perchlorid  of  formyl,  281.  See  also 
Chloroform 

Pericardium,  tapping  of,  under  local 
anesthesia,  505 

Pericementitis,  injection  of  anesthetic 
solution  in,  547 


INDEX 


933 


Pericementitis,  use  of  ethyl  chlorid  eon- 

ti'a-indieated  in,  538 
Peridental  anestliesia,   547 
Perineum      operations,      under      spinal 
analgesia,  587,  597 
site  of  spinal  puncture  for,  610 
Perineural  injection  of  anesthetic  solu- 
tions in  dentistry,  548-552 
in  extremities,  506,  507 
in  local  anesthesia,  490 
in  lower  lip  operation,  498 
of  posterior  tibial  nerve,  direction  of 
needle  in,  509 
Periosteal  injection  in  local  anesthesia 

of  mastoid  process,  499 
Periosteum,     anesthetization     of,     476, 
496 
injection  of,  511 

in  local  a,nesthesia,  509 
in  lower  jaw  operations,  498 
Peritoneal    infections,    ether    treatment 

in,  671,  674 
Peritoneum,  effect  of  shock  on,  386 
parietal,    local    anesthesia    of,    516- 

518,  521 
visceral,  lack  of  pain  sense  in,  517 
Peritonitis,  administration  of  fluid  per 
rectum  in,  375 
anesthesia  in,  356 
with  drainage,  375 
Permeability   of  cell  membranes,   anes- 
thesia and,  53-55 
Peronin,  715,  802 
Peroxids,  in  preparation  of  oxygen,  894 

presence  of,  in  ether,  867 
Personality  of  anesthetist,  652 
Personne,   on  decomposition  of   chloro- 
form,  884 
Peterka's     figures     on     ethyl     chlorid, 

849 
Petrolatum  with   menthol,   as   a   spray, 
preceding  adenoid  and  tonsil  op- 
erations, 341 
Petroleum,  preparation   of  ether   from, 

862 
Petroleum  spirit,  284 
Pharmacopoeia  Helvetica,  ethyl  chlorid 

tests  prescribed  by,  258 
Pharyngeal  insufflation  with  ether,  sta- 
tistics of,  856 
Pharyngeal  tube,  390,   391 
Connell's,  392 
Ferguson 's,  391 
Hewitt's,  390 

in  nose  and  mouth  operations,  234 
Meltzer  's    for    artificial    respiration, 
400 
Pharynx  operations,  colonic  ether  indi- 
cated in,  457 
Phenetidy-acetphenetidin    hydrochlorid, 

765 
Phenol,  692,  718.    See  also  Carbolic  acid 
Phenol  camphor.     See  Camphor,  phenyl- 

ated 
Phenolcocain,   726.     See  also  Cocainum 
phenylicum 


Phenolphthalein   in   testing  chloroform, 
890 
in  testing  ether,  866 
I'henylacetyl,    688 
I'henyl-urethane,  802,  803 
Phenyphrin,  803 

Plilebitis  following  sequestration  anes- 
thesia, 473 
Phoenixin.      See    Carbon    tetrachlorid, 

803 
Phosphorus    pentoxid,     in     preparation 

of  ethyl  chlorid,  252 
Phthisis,  anesthesia  in,  330 

nitrous    oxid    anesthesia    contra-indi- 
cated in,  136 
Physician,  civil  liability  of,   681 
criminal  liability  of,  685 
ethical  liability  of,  680,  681 
liability  of,  growing  out  of  gross  ig- 
norance or  negligence,  685,  686 
qualifications  of,  679 
statutory  liability  of,  686,  687 
Physiologic  rest  in  treatment  of  shock, 

404 
Physiology  of   cerebrospinal  fluid,   563 
of  chloroform,  297-310 
of  inhalation  anesthetics,  in  general : 
effects   of   inhalation  anesthetics 
upon  various  parts  of  the  organ- 
ism, 56-62 
introductory  remarks,  30-32 
modifying  factors,  62-99 
theories   of   the    action   of   general 
anesthetics,  32-56 
of  intravenous  anesthesia,  524 
of    oil-ether   colonic   anesthesia,    462- 
463 
Pictet  chloroform,  877,  880,  881 
Pilling  chloroform  dropper,   312 
Pinneo's    ether    vapor    apparatus,    234, 

235 
Pinneo  's    mouth    tube    for    continuous 

vapor  anesthesia,  236 
Piperidin,   804 
Piperonal,  688 
Pitha,  use  of  morphin  hydrochlorid  by, 

779 
Pituitary  extract  injection  in  cases   of 

shock,  404 
Plasma  cells  of  the  neuroglia,  in  anes- 
thesia, 36,  37 
Plasma-membranes,    role    of,    in    anes- 
thesia, 53-55 
Plecavol,  803 
Pleistopon,   803 

Plethoric  patients,  preliminary  medica- 
tion in  anesthetizing,  371 
Pleura,  aspiration  of,  under  local  anes- 
thesia, 505 
Pleurisy,  anesthesia  in,  329 

chloroform  indicated  for,   310 
"Pneumatic  Institute,"  118 
Pneumonia  after  ether,  189 
anesthesia  in,  329,  330 
from    aspiration     during    anesthesia, 
prevention  of,  364 


934 


INDEX 


Pneumothorax,     intratracheal     insuffla- 
tion in,  418 
Poggiolini   on   blood   changes   in    anes- 
thesia, 58 
"Poho  oil,"  807 

Poisoning,  chloroform.     See  Chloroform 
poisoning 
due  to  cocain,  cause  of,  478,  479 
nitrous  oxid-oxygen  in  seizures  from, 

667 
opium,  432 
Pollock,  on  chloroform,  25 
Polychloral,  803 

Polyehlorated   hydrochloric   ether,    748. 
See     also     Ethyl     chlorid     poly- 
ehlorated 
Pompilian,    Mile.,    experiments    of,    on 

electric  anesthesia,  628 
Popliteal    glands,    enlargement    of,    in 

status  lymphaticus,  332 
Popov,  on  influence  of  light  on  chloro- 
form, 886 
Poppert   on   effect    of   ether   vapor    on 

the  lungs,   101 
Poppy-seed      oil     as     preservative     of 

chloroform,  292 
Porter  on  the  trained  anesthetist,  676 
Post-anesthetic     pneumonia,     effect     of 

warming  the  agent  on,  70 
Post-anesthetic   toxemia,   413-415,   832 
Post-mortem     examination     in      status 

lymphaticus,   335 
Post-operative    gas    pains,    causes    and 

prevention  of,  405,  406 
Posture  during  local  anesthesia,  486 
during    oil-ether    colonic    anesthesia, 

461 
during  sequestration   anesthesia,   470 
during  spinal  analgesia,  613,  614,  625 
for    adenoid    and    tonsil    operations, 
345-352 
Potassium  hydroxid,   in  testing  chloro- 
form, 890 
in  testing  ether,  866 
Potassium    permanganate    in    disinfec- 
tion of  mouth,  364 
Potassoeain,  803 

Pregnancy,  electric  analgesia  contra-in- 
dicated in,  635 
Preliminary     medication,     dosage     for, 
372,  373 
importance  of,  369,  370 
in   intravenous    anesthesia,   524,    532, 

533 
in    oil-ether   colonic   anesthesia,    460, 

461 
in     thyroid     operations     under     local 

anesthesia,  502 
indications  and  contra-indications  of, 

373 
lack  of,  ill  effects  of,  381 
rules  for,  371,  372 
time   for    giving,   372 
See  also  Morphin  and  Atropin 
Preliminary      treatment      in      ordinary 
eases,  364-374 


Preliminary  treatment,  hygienic,  364-366 
medical,  370-378 
psychic,   366-370 
preparation    of    patient    for    colonic 

ether  anesthesia,  450 
for  oil-ether   colonic  anesthesia,  460, 

461 
for  spinal  analgesia,.  612-613 

Preservatives  in  ready-made  anesthesia 
solutions,  540 

Pressure,  estimation  of,   in  colonic   ab- 
sorption of  ether,   440 
in  anesthetization  of  skin,  493 
in  local  anesthesia,  477 
regulation  of,   in  colonic  ether  anes- 
thesia, 443 

Pressure  anesthesia,  552 

Priestley,  discovery  of  nitrons  oxid  by, 
118 
discovery  of  oxygen  by,  893 

Prinz,  Hermann,  on  local  anesthesia  as 
applied  in  dentistry,   335-553 

Proctoclysis  in  anesthesia,  375 

Propasin.     See  Propesin 

Propesin,  803 

Propion,   689,   804 

Propione,  804 

Propyl  in  chloroform,  285 

Propyl  alcohol,  impurities  in  ethyl 
chlorid  due  to,  253 

Propyl  ester  of  dimethyl-amino-oxy- 
benzoyl-isobutyric  acid,  820 

Propylene,  689 

Prostatectomy   under    local    anesthesia, 
513 
under  spinal   analgesia.  Young 's  op- 
eration for,  592 

Proteid  compound  theory  of  anesthesia, 
44,  45 

Protoplasm,  physicochemieal  constitu- 
tion of,  52 

Protoplasmic  respiration  and  anes- 
thesia, 42,  43 

Pseudotropin-liebermann,    832,   833 

Psoas  sinus  enlargement  in  child  under 
spinal  analgesia,  Lusk's  case  of, 
584,  585 

Psychic  influences  and  surgical  anes- 
thesia, 650,  651 

Psychic  shock,  384-387 

Psychic  treatment  preliminary  to  anes- 
thesia,  366-370 

Puerperal  eclampsia,  anesthetic  treat- 
ment for,  667 

Puerperal  sepsis,  sequestration  anes- 
thesia contra-indicated  in,  470 

Puff-ball,  804 

Pulmonary  anesthetics,  preliminary  use 
of  morphin  in,  370,  371 

Pulmonary  complications  after  ether, 
Otte  on,  199 

Pulmonary  method  preliminary  to  colo- 
nic method,  451 

Pulmonary  tuberculosis,  chloroform  in- 
dicated for,  310.  See  also 
Phthisis 


INDEX 


935 


Pulp,   dental,   method  of  anestlietizhig, 

552,  553 
Pulpitis,  use  of  ethyl  chlorid  contra-in- 
dicated in,  538 
Pulse  and  shock,  383,  410-413 
in  anesthol  anesthesia,  277 
in    chloroform     anesthesia,     307-309, 

316 
in  ethyl  chlorid  anesthesia,  274 
in      ethyl-chlorid-oxygen      anesthesia, 

278 
in  intratracheal  anesthesia,  429 
in  nitrous  oxid  anesthesia,  133 
in    oil-ether   colonic    anesthesia,    462, 

463 
in  operations  under  anoci-association, 

405,  406 
in  spinal  analgesia,  582 
Pulselessness     in     overdose     of     ethyl 

chlorid,   261 
Puncture    site,     cotton     and     collodion 
dressing  on,  622,   623 
location  of,  in   spinal   analgesia,  620 
painted    with    iodin    in    spinal    anal- 
gesia, 618 
Pupillometer,  195,  308 
Pupils    in    chloroform    administration, 
306,  308,   315 
in  colonic  ether  administration,  453 
in  ethyl  chlorid  anesthesia,  262 
Pyemia,    spinal    analgesia    contra-indi- 
cated in,  587 
Pyknometer     for     determining     specific 
gravity  of  chloroform,  889 
for    determining    specific    gravity    of 
ether,  864,  865 
Pylorectomy     under     spinal    analgesia, 

560 
Pyridin,  804 

Pyroacetic   ether,   689.      See   also   Ace- 
tone 
Pyrocain,   804 

* '  Pyrogenous ' '  oil  in  chloroform,  285 
Pyrollidin,  804 
Pyrrol,  714,  804,  805 

Quincke 's     experiments     with     lumbar 

puncture,  557,  559,  563 
Quinin,  540 

and  urea  hydrochlorid,  805 
in  anesthetic  block  for  shock  preven- 
tion, 406 
in  gastro-enterostomy,  356 
solutions  of,  in  local  anesthesia,  478 
Quinin  alkaloids,  805 

Eadestock  's  mixture,  807 

Eadikal-anasthetikum  apotheker  Maier, 
807 

Eadinin,  807 

Eamsay,  on  decomposition  of  chloro- 
form, 885 

Eape,  anesthesia  and,  687 

Eapid  respiration,  anesthesia  by,  807 

Eathery  on  effects  of  ether  on  kidneys 
and  liver,  190 


Kaueher  on  effect  of  ether  on  lactation, 

192 
Kebrcathing,  advantages  of,   113 

charts    showing    effect   of,    on    pulse, 
respiration,    and    blood    pressure, 
105,   106,   107 
in  administration  of  anesthetics,  99- 

116 
in   chloroform   administration,    317 
in    chloroform-ether-nitrous    oxid    se- 
quence,   141,    142 
in  colonic  ether  anesthesia,  451,  452 
in  nitrous  oxid  anesthesia,   137,   140, 

141,    142 
in     nitrous     oxid-oxygen     anesthesia, 

129,  144,  145,   159,  166,  167 
in  oil-ether  colonic  anesthesia,  462 
in  shock  cases,  112 
Eeclus,  478,  489,  539,  753 
Eectal  anesthesia,   225 

by  colonic  absorption  of  ether,  433- 

458 
in  diseases  of  the  lungs,  330 
preliminary  use  of  morphin  in,  370 
statistics  for,  843,  855 
Eectal  cases,  anesthesia  in,  355 
Eectal  diseases,  cyclorenal  in,   732 
Eectal  ether,  statistics  for,  842 
Eectal  infusion  in  shock  prevention,  404 
Eectal  tube  in  colonic  ether  anesthesia, 

443,  449,  451,  461,  463 
Eectification  of  ethyl  chlorid,  253 
Eectum,  sagittal  section  of,  517 

surgery    of,    under    local    anesthesia, 
514,    515,    516,    517 
under  spinal  analgesia,  587 
Eedistillation   of  ethyl   chlorid,   253 
Eedwood,   on   action   of   sulphuric   acid 

on  chloroform,  878 
Eeflex,  lid,  in  oil-ether  colonic  anesthe- 
sia, 462 
Eeflexes,  after  anesthesia,  378 

cutaneous,   and  surgical   shock,  383 
in   chloroform    anesthesia,    307,    308, 

315,   316 
in  ethyl  chlorid  anesthesia,  260,  262, 

263 
in  nitrous  oxid  anesthesia,   133 
Eegional    method    of    local    anesthesia, 

490 
Eegionary    anesthesia,     eueain    lactate 

anesthesia  for,   758 
Eegnault,       formation       of       carbonyl 
chlorid     in     chloroform     demon- 
strated by,  884 
on  chloroform,  873 
Eeicher's  theory  of   anesthesia,  47,  48 
Eeichel's  zahnschmerzstillende  Tropfen, 

807 
Eemoval    of    patient    after    operation, 

technique  of,   377 
Eenal  function,  effect  of  anesthesia  on, 

60 
Eenocain,   808 
Eenoform,  808 
Eesistanee   to   surgical   shock,    383,    384 


936 


INDEX 


Respiration   and   shock,   383,   385,   410- 
413 
during    oil-ether    colonic    anesthesia, 

462,  463 
e&eet  of  warming  the  agent  on,   65 
in  anesthesia,   57 
in  anesthol  anesthesia,  277 
in    chloroforin    administration,     287, 

288,   298,   313,  316 
in  ethyl  chlorid  anesthesia,  258,  263, 

274 
in    ethyl    chlorid-oxygen    anesthesia, 

278 
in  nitrous  oxid  anesthesia,   127,   133 
in  sequestration  anesthesia,  469,  472 
in  stage  of  overdose  of  nitrous  oxid, 

134 
rapid,  aiiesthesia  by,  807 
Eespiratory     conditions     under     spinal 

analgesia,  582 
Eespiratory  difficulties  during  anesthe- 
sia, 380,  381 
Eespiratory  failure  due  to  loss  of  car- 
bon dioxid  in  blood,   406-408 
Eespiratory    system,    anesthesia   in    op- 
erations on,  339 
effect  of  anesthetics  on,  56,  57 
effect  of  ether  upon,  185,  192,  248 
effect  of  ethyl  chlorid  on,  258,  259, 

269 
effect  of  nitrous  oxid  on,  127,  128 
reflex   changes   in,   in   anesthesia,   62 
See  also  Lungs 
Eetching  during  anesthesia,  381 
Eey,  Jean,  893 

Eeyne's  anesthetic  mixture,  689,  702 
Eeynier,  on  nirvanin,   781,   782 
Rhein,  methyl  chlorid   as   a  refrigerat- 
ing agent  introduced  by,  537 
Ehigolene,  808 

Ehinolaryngology,  novocain  in,   784 
Ehinosol,  808 
Eib  resection  for  empyema  under  local 

anesthesia,  505 
Richardson,   methyl   alcohol   introduced 
by,   773,   774 
methyl  bromid  introduced  by,   774 
methyl  chlorid  introduced  by,   775 
methyl  ether  introduced  by,  776 
methylal  introduced  by,   776,  777 
methylene     chlorid     introduced     by, 

777 
methylene   ether   introduced   by, 
methylic-ethylic    ether    proposed 

778 
on  amyl  nitrite,  698 
on  amylene,  698 
on  butyl  chlorid,    718 
on  carbon  dioxid,   719 
on   carbon   disulphid,   720 
on  ethyl  bromid,  738 
on    ethylene  ■  chlorid,    749 
on  hydramyle,  767 
on  local  anesthesia,  477 
on  methane,   773 
on  puff  ball,  804 


778 

by, 


Eichardson,  on  turpentine,   837 

statistics     of,     for     ether     and     for 
chloroform,  853 
Eichardson  's  methylen  chlorid,  808 
Eichardson 's  mixture,  689,  808 
Eichardson 's  voltaic  narcotism,  536 
Eigidity,    muscular,    during   anesthesia, 
381 
induced  by  hypnosis,  659,  660,  663 
Eingen's  solution  in  intravenous   anes- 
thesia, 525,  532 
with  carbon  dioxid  in  prevention  of 
shock,  409 
Ritsert's  anesthesin,  702 
Eoaf  theory  of  anesthesia,  44-46 
Eobinovitch,     Louise     G.,     on     electric 
analgesia,    sleep,    and    resuscita- 
tion,  628-643 
Eobiol,  808 

Eohricht  on  glycosuria  after  ether,  198 
Eolland,  somnoform  introduced  by,  818 
Eose,  Valentin,  on  ether,  860,  863 
Eoth-Drager     oxygen     and     chloroform 

apparatus,  317-320 
Eottenstein,   on   ethyl   chlorid   as   a   re- 
frigerating agent,   537 
Eoux,  on  decomposition  of  chloroform, 
884 
on  spinal  analgesia,  604 
Rouxeau,     physiological     investigations 

of,  on  electric  sleep,  629 

Eouxeau    and    Leduc,    experiments    of, 

on  electric  anesthesia,   628 

on  electric  resuscitation,   637 

Eoyal  Medical  and  Chirurgical  Society 

Committee  mixture,  808 
Eump,   on   effect   of   air    and   light   on 

chloroform,   884 
Eyall  on  spinal  analgesia,  587,  604,  610 
Eyan  and  Guthrie  on  magnesium  salts, 

771 
Eymer  and  nitrous  oxid,   24 

Safrol    as   preservative   of   chloroform, 

292 
Sahli,  pantopon  introduced  by,  798,  799 
Saison  on  effects  of  ether  on  the  liver 

and  kidneys,  190 
Sal  angestheticum  Schleichii,   808,  809 
Salicylchloroform,    877 
Saline    enema    during    anesthesia,    374, 
375,   376 
in  acid  intoxication,  414 
in  post-operative  treatment,  378,  379 
in  preliminai'y  medication,   373 
in  treatment  of  shock,  '374 
Saline    infusion    in    shock    prevention, 
403,  404,  409 
intravenous  administration  of,  in  oil- 
ether  colonic  anesthesia,  462,  463 
intravenous    infusion    of,    effect    of, 

on  blood  pressure,  403 
normal    physiologic,     as    vehicle   for 
analgesic  drugs  in  local  anesthe- 
sia, 479 


INDEX 


937 


Saline,  use  of,    following    adenoid    and 
tonsil  operations,  345 
in  acute  mania,  669 
in    eocain    solutions,    480,    481 
in  eocain  sterilization,  605 
in  intravenous  anesthesia,  525 
in   spinal  analgesic   solutions,   599, 
603 

Saline  solution  and  glucose,  use  of,  pre- 
ceding anesthesia  in  cancer,  330 

Saline  solution  infiltration  in  local  an- 
esthesia, 489 

Saline  solution  injection  into  sub- 
arachnoid  space,  557 

Salivary    glands,    effect    of    anesthesia 
on,  60 
effect  of  warming  the  anesthetic  on, 
70 

Salolcamphor,    809 

Salolum  camphoratum,  809 

Salpingectomy  under  spinal  analgesia, 
560 

Salts,  antagonism  between  anesthetics 
and,  55 

Salts  of  arabic  acid  with  anesthetic 
bases,  713 

Salvarsan  method  of  introducing 
needle  in  intravenous  anesthesia, 
528 

Sander's  chloroform  vapor  generator 
in    colonic   ether   apparatus,   444 

Sanoform  preparations,   809 

Sanovagin,  727.  See  also  Coeainol- 
ereme 

Sansom's  A.  C.   mixture,  809,  810 

Saponin  with  chloroform,  284 

Scalp,  anesthetization  of,  496,  497 
eocain  solution  for  local,  497 
nerve  supply  of,  497 

Scar  removal  under  local  anesthesia, 
495 

Sehacht  on  Pictet  chloroform,  877, 
880,   881 

Schafer  and  Scharlieb's  A.  C.  mixture, 
810 

Schall  on  oxygen  and  chloroform,  27 

Scheele,  oxygen  prepared  by,  893 

Schering's  method  of  preparing  chloro- 
form, 873 

Schleich's  anesthetics,  810 

Schleieh's  experiments  with  anesthetic 
mixtures,  702-705 

Schleich's   infiltration   anesthesia,   755 
acoin  in,  690 
alypin  in,  693 
in  spinal  analgesia,  559 
use    of    tropacocain    hydrochlorid    in, 
833 

Schleich's  method  of  anesthesia,  484, 
489,  808,  809 

Schleich's  solution  No.  2,  statistics  for, 
842 

Schleich's  theory  of  anesthesia,  35,  36 

Sehmitt  on  eueain-B,   754 

Schneiderlin-Korff  method  of  anesthesia 
by  morphia  and  scopolamin,  811 


Schoorl  and  Van   den  Berg,  on   decom- 
position of  chloroform,  887 
Schraff'  's    discovery    of    local    analgesia 

with  coeain,  555 
Sciatica,  eucain-B  in  treatment  of,  755 
Sclerosis  of  arteries,  nitrous  oxid  anes- 
thesia contra-indicated  in,  135 
Scopolamin,  in  goiter,  354 

in  intravenous  anesthesia,   524,   533 
in  preliminary  medication,  doses  for, 
372 
for   colonic   ether   anesthesia,    450, 

454 
for  nitrous-oxid-oxygen  anesthesia, 
165 
Scopolamin  hydrobromid,  810-817 
Scopolamin-morphin    injection    in    local 

anesthesia,   486 
Scopolamin-morphin-ether       anesthesia, 

813 
Scopolamin-morphin-ether        chloroform 

anesthesia,  814 
Scopolamin  tablets,  813 
Scopomorphin,  817 
S-dichlorethane,  749,  750 
Sealed  tube  of  ethyl  ehlorid,  254 
Seasickness,  antivom  in,  712 
Sebaceous  cyst  removal  under  local  an- 
esthesia,   495,   496 
Seelig  on  ether  inhalation,  198 
Selection   of   anesthetic,   conditions  af- 
fecting, 324-326 
for  special  operations,  337-357 
rules  to  be  observed  in,  326-337 
Semi-closed    method    of     administering 

ethyl  ehlorid,  272,  273 
Sensory    innervation    of    mucous    mem- 
branes of  head,  499 
Sensory  nerves,  eocain  experimentation 

on,  556 
Sensory  paralysis  in  venous  anesthesia, 

492 
Sepsis,     spinal     analgesia     contra-indi- 
cated in,  587 
Septicylat,  817 

Sequestration  method  of  anesthesia,  ad- 
vantages of,  470-473 
contra-indieations  to,  469,  470 
disadvantages  of,  473 
history  of,   467,  468 
indications  for,  469 
modifications  in  method  of,  470 
technique  of,  468,  469,  471,  472 
with  upright  position,  473-475 
Shock,  anesthetic,  387-401 
anticipation  of,   410-413 
causes  of,  401,  405 
dietetic,   387 

diminution  of,  in  upright  position  for 
adenoid    and    tonsil    operations, 
352 
due  to  obstructed  airway,  389 
due  to  overdose  of  anesthetic.  388 
duration  of  operation  and,  386 
during  anesthesia,  374,  389 
effect  of   hemorrhage   on,   387 


93S 


INDEX 


Shock,  effect  of,  on  cerebrospinal  fluid, 
565 
effect  of  pituitary  extract  on,  404 
effect  of  posture  on,-  402,  404 
effect  of  preliminary  medication  on, 

371 
from  labial  stertor,  390 
in  operation. on    appendix,   413 
in  spinal  analgesia,  581,   587,   595 
intravenous  infusion  and,  404 
physiologic  rest  in  treatment  of,  404 
post-operative,    adrenalin    in   preven- 
tion of,  373 
prevention   of,   376,    379,   382-413 
by  Crile,  402-406 
by   support   of   circulation,   404 
Henderson  on,  409 
in  local  anesthesia,  485 
Keen 's  measures  for,  404 
measures  for,  by  Latham  and  Eng- 
lish,  403 
saline  infusions  in,  404 
water  in,  366 
psychic,  384-387 

reduction   of,    in   colonic   ether   anes- 
thesia, 457 
surgical,  383,   384 

and  time  of  day,  384 
susceptibility  of  organs  to,  402,  403 
theories  of  cause  of,  401 

Crile 's    vasomotor    paralysis,    402- 

406 
Henderson 's     vasomotor     activity, 
406 
treatment  of,  392-401,  666 
treatment    of,     in     accordance    with 
Crile 's  theory,  403-406 
Shoulder  amputation  imder  local  anes- 
thesia, 490 
Shuttle^sorth 's     method     of     purifying 

chloroform,  879 
Sicard  on  spinal  analgesia,  558,  566 
Sicard's  experiments  on  injections  into 

•subarachnoid  space,  557,  558 
Sicherheitsbenzih,    817 
Silliman,     chloroform     confused     with 
ethylen  dichlorid  by,  871 
on  production  of  chloroform,  872 
Silver  nitrate  in  testing  purity  of  oxy- 
gen,   895 
Simpson,  Sir   James  Y.,   8,   20,    21,  22, 
25,  177,  282,  286,  311,  689,  713, 
720,  749 
Simpson 's  ' '  Anaesthesia, ' '  21 
Simpson's  "New  Anaesthetic,"   20,   21 
Sims'  position  in  oil-ether  colonic  anes- 
thesia, 461,  465 
Sinecain,  817,  818 

Skin,    appearance    of,    in    nitrous    oxid 
anesthesia,   133 
local   anesthetization  of,  493-496 
production   of  wheal  in,  493-495 
solution    for,    494 
Skin    affections,     ethyl    aminobenzoate 

in,    737 
Skin   and   surgical   shock,   383 


Skin   grafting  under  colonic   ether   an- 
esthesia,   454 
under  local  anesthesia,  511 

Skin    injection,    solution    for,    in    local 
anesthesia,   480 

Skin  reflexes  due  to  shock,  385 

Skopomorphin.     See  Scopomorphin 

Sleep,   51 

difference    between    anesthesia    and, 
50 

Sleeping    child,    method    of    anesthetiz- 
ing,   341,    342 

Skull  examination  under  local  anesthe- 
sia, 496 

Skull    fracture,    operation    for,    under 
colonic   ether   anesthesia,   456 

Smokers,   ethyl    chlorid   anesthesia   con- 
tra-indicated  in,   269 

Snape  's   ' '  calorific  fluid, "  536  • 

Sneezing  during  anesthesia,  cocain  for, 
381 

Snow,  John,  25,  177,  283,  713,  719,  720, 
749 

Snow's  inhaler,  23 

Soapsuds  enema  after   oil-ether  colonic 
anesthesia,   463 
in   after-treatment   for   colonic   ether 

anesthesia,   453 
in  preliminary  treatment,   375 
for  colonic  ether  anesthesia,  450 

Sobbing  in  anesthesia,  380 

Sodium   bromid  in  post-operative   vom- 
iting, 379 

Sodium    carbonate    in    preparation    of 
chloroform,  879 
in  purification  of  chloroform,  285 

Sodium   chlorid,   in   preparation   of   co- 
cain solutions,  539 
in  preparation  of   ethyl   chlorid,   252 
in    spinal     analgesic     solution,     601, 

602 
with  cocain  in  local  anesthesia,  480, 
482 

Sodium    hydroxid    as    preservative    of 
chloroform,    291 
in  testing  purity  of  oxygen,  895 

Sodium  nitrite,  401 

Sodium    nitroprussid    solution    in    test- 
ing  chloroform,   890 

Sodium  thiosulphate,  in  purification  of 
chloroform,   879 

Scemnoforme.      See   Somnoform. 

Soloid    "hemisine"    comp.    c.    eucaino, 
818 

Solubility  of   chloroform,   284 

Soluble     hypodermic     tablets    novocain 
%    grain,    818 

Soluble  tablets  novocain  1   1/7  grains, 
818 

Solution    atoxyl,     10    per    cent.,    with 
novocain,   1   per  cent.,   818 

Somnambulism,   hypnotic,   654 

Somnoform,    276,    818,    819 
and   local  anesthesia,   856 
effect   of,   on   diaphragm,   258 
statistics  for,  856 


INDEX 


939 


Somnoform-cliloroform,     statistics    for, 

856 
Somnoi  or  m-other-clilorof  orm,     statistics 

for,    856 
Somnolence,   hypnotic,   654 
Soubeiran,  discovery  of  chloroform  by, 

871,   873 
Souligoux  on  ether  in  the  treatment  of 

infections,   671,   672 
Spasm,    muscular,    in     asphyxia,    with 

ethyl  chlorid,  261 
Spasms,   muscular,    due   to   chloroform, 

303 
Specialist,  liability  of,  684,  685 
Speier's    ansesthin    and    anaesthol    solu- 
tion,   702 
Spencer's  theory  of  anesthesia,  32-34 
Spermaceti,     purified,     as    preservative 

of    chloroform,    292 
Sphincter   ani,   dilatation  of,  463 

in  treatment  of   shock,    393 
Spielmeyer's     experiments     in      spinal 

analgesia,  570,  571 
Spiller     and     Leopold's     experiments, 
with  stovain  in  spinal  analgesia, 
569,   570 
Spilsbury     and     Cross,     on    purity     of 

chloroform,    882 
Spinal    analgesia,    554-627 

advantages     and     disadvantages    of, 

594-596 
alypin  in,   693 
analgesic   agents   for,    599-604 

sterilization   of,    604,    605 
anatomical  and  physiological  consid- 
erations' in,   563-572 
apparatus  and  materials  for,  614-616, 
617 
sterilization   of,    616,    617 
auto-operations   under,    577,   580 
Babcock's   solution   for',   603 
Barker 's      stovain-glucose      solution 

for,  602,   603 
Bier's  stovain  solution  for,   602 
Bier's  tropacocain   solution   for,   601 
Braun  's    novocain-suprarenalin    solu- 
tion  for,    603,    604 
by    tropacocain,    601,    835,    836,    837 
case   reports   on,   623-627 
cases  of   complete,   574,   575,   576 

in  children,   588-590 
Chaput  's  stovain  solution  for,  602 
course   of,   572 
deaths  due  to,  596-598 
decrease      of      post-operative      pneu- 
monias imder,  199 
discovery  of,  555-563 
duration   of,   576,   577 
early  application  of,  to  surgery,  559- 

563 
Erhardt's  solution  for,  601 
extent   of,   572-576 
facial    expression    of    patient    under, 

575 
first    surgical    operation    under,    559, 
560 


Spinal  analgesia,  Gray's  dextrin-stovain 
solution  for,  603 
history  of,  555-563 
in  diseases   of  the  lungs,  330 
in   heart    disease,   329 
in    obstetrics,    593,    594 
indications      and      contra- indications 
for,    586-594 
opinions  of   surgeons   on,   586,   587 
injection   with    patient    in    recumbent 

position,    614 
Jonnesco's      stovain-strychnin      solu- 
tion for,  603 
Meyer's   solution   for,    601 
operations   on   the   aged   under,   591, 

592 
phenomena    accompanying,    577-582 
objective,  581,  582 
subjective,  577-581 
postoperative     phenomena     of,     582- 

586,   595,   596 
preliminary   use   of   morphin   in,    370 
preparation    of    patient   for,    612-614 
scopolarnin  sleep  combined  with,  813 
sites  of  injection  in,  564,  605-612 
statistics  for,   842,  843,  855 
technique   of   injection   in,   595,   617- 

623 
typical   satisfactory   case  of,   625 
Spinal  cord,  cocain  experimentation  on, 
556-559 
illustrations   of,    608-610 
lesions    of,    spinal    analgesia    contra- 
indicated   in,   587 
Spinal    neurons,    effects    of    anesthesia 

on,   41 
Spinal  puncture,  early  experiments  in, 
557,    558 
Lusk  on,   605-607 
patient  in  sitting  posture  for,  613 
routes  for,  605,   607-610 
Eyall's   method   of,   610 
schematic   pictures    showing   location 
of     space     between     third     and 
fourth  lumbar  vertebrse,   611 
Spinal  puncture   site,   location   of,   618 
Avamreseo  's,    610 
Gray's,   610 
Jonnesco  's,   607,   608 
painted  with  iodin,  618 
Spinal    support    during    local    anesthe- 
sia, 486,  487 
Spine,       diagrammatic       cross-sections 

through,  606 
Spleen,      enlargement      of,      in      status 

lymphaticus,    332 
Spraying  nozzle   for  ethyl  chlorid,   254 
Squibb  on  manufacture  of  ether,  860 
Staphylorrhaphy    under     colonic     ether 
anesthesia,   439,   454,   456 
under  rectal  etherization,  435 
Starfish  eggs,  effect  of   anesthetics  on, 

43,  44 
Starvation,  acidosis   in,  415 
Starvation      cases,      gastroenterostomy 
in,   356 


940 


INDEX 


Statistics,   841-857 
American,  843 

for   1905-1912,   854-856 
comparison   of   American    and   Euro- 
pean,  853,   854 
comparison    of    1905-11,    with    1892, 

853 
for  anesthol,   848 
for  auesthol-ether  sequence,   847 
for   chloroform,'  851,    852 
for   chloroform-ether   sequence,    847 
for   chloroform-oxygen,    851 
for  ether,   848 
for  ethyl  chlorid,  848-850 
for  ethyl  chlorid-ether,  848 
for  intratracheal  anesthesia,  852 
for  local  anesthesia,  844 
for  nitrous  oxid,  844 
for    nitrous    oxid    with    oxygen,    844- 

847 
for  nitrous   oxid-ether   sequence,   848 
for    oil    of    bitter    orange    peel-ether 

sequence,    852 
U.  S.  army,  842,  852 
U.  S.  navy,  842,  852 
See  also  under  various  anesthetics 
Status   lymphaticus,   326,    327 
anatomy  of,  331,  332 
chloroform    contra-indicated    in,    310 
choice     of    anesthetic     in     suspected 

cases   of,   333 
definition   of,   331 
diagnosis   of,   332,    333 
ether  for,  247 
history  of,  331 
mortality   from,  334,   335 
observations  on,   in  animals,   335-337 
post-mortem  examination   in,   335 
preparation    for    operation    in,    333, 

334 
treatment   of,   during   anesthesia,  334 
Statutory    liability    of    physician,    686, 

687 
Stenocarpin,  819 
Stephan's  analgos,   710 
Stephen's  mixture,  819 
Sterilization   of   analgesic   agents,    604, 
605 
of    apparatus    for    spinal    analgesia, 
616,   617 
Sterno-mastoid    excision    under    colonic 

ether  anesthesia,  454 
Stertor  in  anesthesia,   380,   464,   465 
in    chloroform    administration,    307 
in  ethyl  chlorid   anesthesia,   274 
in   oil-ether   colonic   anesthesia,   462 
labial,  shock  from,  390 
prevention      of,      during     anesthesia, 
392 
Stimulation,    peripheral,    during    anes- 
thesia,  380,   381 
Stitch  irritation,  prevention  of,  by  an- 
esthetic block,  406 
Stockman    and   nitrous    oxid,   5 
Stomach,  care  of,  preliminary  to  local 
anesthesia,  486 


Stomach   operations,   shock   in,   403 
Storage  of   ethyl  chlorid,   254-256 
Stovain,  540,  692,  819-828 

in    spinal    analgesia,    563,    576,    582, 
599,   603,  624,  625,  626 
with   adrenalin,   592 
with    strychnin,    828,    829 
Stovain  injection  by  lumbar  puncture, 
effect    of,    on    nervous    system, 
569,  570,   571,  572 
Stovain   solutions   in   spinal    analgesia, 
602,    603 
diffusible,   585 
Stovain-Billon,  828 

in  spinal  analgesia,  602,  603 
Stovain- dextrin  solution  in  spinal  anal- 
gesia, 592 
Stovain-glucose  solution  in  spinal  anal- 
gesia,  602,   603 
Stovain-strychnin     solution     in     spinal 

analgesia,    582 
Strophanthin,  829 
Strychnin,   stovain  with,  828,  829 
use   of,   in   respiratory    disturbances, 
539 
in  respiratory  failure,   394 
in    spinal    analgesia,    563,    582,    585, 
599,    603,   604,   612 
Strychnin    injection    in    shock    preven- 
tion, 403 
Strychnin    poisoning,    anesthetic    treat- 
ment for,  667 
chloroform  in,   285 
Strychnin    sulphate    in    shock    preven- 
tion,  403 
in   spinal   analgesia,    625 
Sturmann  's    solution,    829 
Stursberg,  on  effects  of  ethej  narcosis 
on  the  blood,  188 
on     temperature     stimulus     in     ether 
and  chloroform  anesthesia,   69 
Subcain,  829 
Subcutin,  829,  830 
Subcutol,  829 
Subicterus,      post-operative,      following 

sequestration  anesthesia,  472 
Submucous    operations,    anesthesia    in, 

340 
Subperiosteal    injection    of    anesthetic 

solutions    in    dentistry,    543-547 
Suffocation,    due    to    enlarged    thymus, 

335 
Suggestibility  in  hypnosis,  654 
factors   influencing,   655,   656 
Suggestion   in   anesthesia,    649-653 
deep  breathing  and,   652,   653 
instead  of  hypnotism,  649,  650 
local   anesthesia   and,   651,   652 
preliminary  medication  and,  653 
value  of,  652 
See  also   Hypnosis 
Sulphate  of  morphin,  use  of,  preceding 

anesthesia,  328 
Sulphates,      preparation      of      oxygen 

from,   894 
Sulphocarbolate.     See  Subcutin 


INDEX 


941 


Sulphophenalylate.      See    Subcutin 
Sulphur,  as  preservative  of  chloroform, 
291,   292 
in   preparation   of  chloroform,   875 
Sulphur   compounds,    test   for,   in   ethyl 

chlorid,   257 
Sulphur  dioxid,  removal  of,  from  ether, 

864 
Sulphuric  acid  in  chloroform,   285 
in    preparation    of    ether,    180,    860, 

862 
in  preparation  of  ethyl  chlorid,  252, 

253 
in    purification    of    chloroform,    878, 

879,  890 
preparation  of  oxygen  from,  894 
Sulphuric  ether,   178,  860 
Sulzberger 's  local   ana3sthetic,   830 
Summopon,  830 

Superior  maxilla    operations    under    co- 
lonic ether  anesthesia,  454 
Suppositoires    adreno-styptiques,    830 
Suprarenalin   in   spinal   analgesic   solu- 
tions, 603,  604 
Suprarenal-tonogen,   830 
Suprarenin,  830 
synthetic,   692 
Suprarenin-cocain  tablets.    See  Braun  's 

Suprarenin    tablets 
Surface  anesthesia,   488,  489 
Surface    tension    theory    of    anesthesia, 

42 
Sutton's  apparatus  for  colonic  absorp- 
tion of  ether,   437,   438,   439 
description  of,  444-450 

afferent  and  efferent  tube  systems, 

449,   450 
complete  with  oxygen  tank,  448 
simple  form  of,   447 
vapor   generator,    444-449 
Sutton's     method     of     ether     adminis- 
tration    by     colonic     absorption, 
441 
administration   in,   451-453 
after-treatment,    453 
preparation    of    patient    for,    450 
technique  of,  450-453 
Sweat  glands,   effect   of  anesthesia  on, 

60 
Sweating  in  spinal  analgesia,  582 
"Sweet  spirit  of  salt,"  250.     See  also 

Ethyl    chlorid 
Sylvester,  use   of  quinin   and  urea  hy- 

drochlorid  by,   806 
Synthetic   suprarenin   with  novocain  in 

local  anesthesia,  482 
Syringe   for   Bier 's  venous   anesthesia, 
491 
for    injections    in    local    anesthesia, 

483,   484 
for  spinal  analgesia,  614 

Tait  on  spinal  analgesia,  560,  561,  562, 

565,   566,    607 
Tait     and     Caglieri's     experiments     on 

the   subarachnoid  space,  565-572 


Tauber,    experiments   of,   with    trichlor- 
ethane,    832 
studies  of,  on  methylchloroform,  832 

Teeple,  on  preparation  of  chloroform 
from  acetone,  874 

Teeth,   cocain   anesthesia   of,   489 
operations    on,    under    local    anesthe- 
sia,   496 
See  also  Dentistry 

Temperature     (body),    effect    of    amyl 
chlorid   on,   697 
effect  of  anesthesia  on,   66,  67 
effect  of  warming  the  agent  on,  67- 

69 
in  colonic  ether  anesthesia,  436,  4-52 
in  oil-ether  colonic  anesthesia,  462 
in     operations     under     anoci-associa- 

tion,   405,   406 
rise  of,  due  to  chloroform  and  ether 

mixture,    706-710 
shock  and,  383,  38.5,  386,  402 

Tendon  transplantation  under  local 
anesthesia,   511 

Tenesmus  in  colonic  ether  anesthesia, 
435 

' '  Terminal    anesthesia, ' '    536 

Terpentinkampfer.  See  Terpin  hydro- 
chlorid 

Terpentinchlorhydrate.  See  Terpin  hy- 
drochlorid 

Terpin   hydrochlorid,    831 

Terpinchlorhydrate,  831 

Terpineol    as    preservative    of    chloro- 
form, 292 
use   of,   preceding   anesthesia,   91 

Testicles,  effect  of   shock  on,  385 

Tetanus,  anesthetic  treatment  for,  667 
chloroform   indicated  for,  310 

Tetanus  toxin  injection  into  subarach- 
noid space,  558 

Teter   auxiliary  tube,   155,   173 

Teter  ether  attachment,  154 

Teter  face  mask,  154 

Teter  method  of  nitrous  oxid-oxygen 
anesthesia,   153-159 

Teter  nasal   inhaler,   155,   156 

Teter  nasopharyngeal  tubes  for  nitrous 
oxid  and   oxygen,   157 

Teter  nitrous  oxid-oxygen  apparatus, 
152,   156 

Teter  vapor  warmer,  153 

Teter 's  case  of  death  in  nitrous  oxid 
and  oxygen  anesthesia,  845,  846 

Tetrachlorethane,  831 

Tetrachlorethylene   in    chloroform,    285 

Tetrahydronaphthalene,   831 

Tetramethyl  -  diamino  -  dimethylethyl- 
carbinol  cinnamate  hydrochlorid, 
831 

Thayer's  method  of  purifying  chloro- 
form,  879 

Thibault,  use  of  quinin  and  urea  hydro- 
chlorid   by,    483,    806 

Thibault 's  local  anaesthetic,   831 

Thin  subjects,  choice  of  anesthetic  for, 
329 


942 


INDEX 


Thirst,     relief    of,    during    anesthesia, 

374,   375 
Thomas'    apparatus    for    colonic    ether 
anesthesia,   437,   444 
for  pharyngeal  anesthesia,  437 
Thompson    on    effects    of    ether    upon 

renal    activity,    190,    191 
Thoracic    surgery,    intratracheal    insuf- 
flation   indicated   in,    431 
under  local  anesthesia,  505,  506 
under  spinal  analgesia,  597 
Three-bottle  vapor  inhaler,   225,   230 

attached  to   oxygen   tank,  240 
Throat   affections,    dysphagin   in   treat- 
ment of,   735 
Throat  operations,  alypin  in,  693 
eucain   lactate   solution   for,   758 
with  Sutton's  colonic  anesthesia  ap- 
paratus, 450 
Thrombosis  after  ether,   186,   199 
Throphene,   714 
Thymicus,    331-337.      See    also    Status 

lymphaticus 
Thymocain,   831 
Thymoform,  831 
Thymol,  692 

as    preservative    of    chloroform,    292 
in   carbon   tetrachlorid   for   steriliza- 
tion   in    intravenous    anesthesia, 
526,  531 
Thymus  gland,   331,   332 
enlargement  of,  333,  335 
See  also  Status   lymphaticus 
Thyroglossal     cyst     operations     under 

colonic  ether   anesthesia,  454 
Thyroid,     enlargement     of,     in     status 
lymphaticus,    332 
operations    on,    methods    of,    503-505 
sequestration    anesthesia   in,    471 
under  local  anesthesia,  502-505 
See   also   Thyroidectomy 
Thyroid    arteries,    ligation    of,    under 

local  anesthesia,  502,  503 
Thyroidectomy,    anesthesia    in,    353 
cocain    solutions  in,   under   local   an- 
esthesia, 480 
intratracheal   insufflation   in,    432 
sequestration  anesthesia  indicated  in, 

469 
under  anoci-association,  406 
under  local  cocain  anesthesia,   581 
Tibia,  osteotomy  of,  under  spinal  anal- 
gesia, 560 
Tilden,  on  action  of  sulphuric  acid  on 

chloroform,  878 
Tin  containers  for  chloroform,   293 
Tissue    asphyxia,    124 
Toe  anesthetization,   507,   511 
Toes,    operations   on,   354 

Esmarch    elastic    bandage    in,    477 
Tongue,     enlargement     of,     in     status 
lymphaticus,    332 
excision   of,   anesthesia   in,    339,   340 
chloroform   indicated  for,   310 
under     colonic     ether     anesthesia, 
435,  454,  455 


Tongue,  excision  of,   under  local  anes- 
thesia, 497,  498 
under   oil-ether   colonic   anesthesia, 

464 
under  spinal  analgesia,   587 
Tongue  forceps,  use  of,   in  anesthesia, 
362 
in   artificial   respiration,    393 
Tonocainum    suprarenale    Eichter,    831 
Tonogen   suprarenale  Eichter,   831 
Tonsil  cases,  340-352 
use  of  ether  for,  247 
use  of  Junker  apparatus  in,  322 
See    also    Adenoid    and    tonsil    cases 
Tonsillectomy,  ethyl  chlorid  anesthesia 
for,   268 
local   anesthesia   for,   500 
sequestration     anesthesia     for,     470, 
474 
Tonsils,     enlargement     of,     in     status 
lymphaticus,    332 
treatment  of,  under  local  anesthesia, 
499,   500 
Torney,  Surgeon-General,  891 
Townley  's   anodyne   mixture,   831 
Toxemia,   induced   by  thymus,   335 
post-anesthetic,   413 
use   of   water    during   anesthesia   in, 
376 
Toxic  causes  of  psychic  shock,   384 
Trachea,      operations      around,      intra- 
tracheal     insufflation      indicated 
in,  432 
operations  on,  colonic  ether  indicated 
in,  457 
Tracheotomy,    anesthesia    in,    352,    353 
under   colonic   ether   anesthesia,   454, 

455,   456 
under  local  anesthesia,   502 
Transfusion   of   blood  in   serious  cases 
of  shock,  404 
preceding   gastro-enterostomy,   356 
Traube  's  theory  of  anesthesia,  42 
Traumatic    surgery,    intravenous    anes- 
thesia in,   492 
Treatment    after    anesthesia,    378,    379 
by     colonic    absorption    of    ether, 

453 
local,   488 
anesthetic,     for     special     conditions, 

666-671 
emergency,  to  insure  breathing,  362, 

363 
for  acapnia,  409 

of  ordinary   cases  during  anesthesia, 

364-379.     See  also    Management 

of  unusual  cases,  379-415.     See  also 

Management 
preliminary,   in   ordinary   cases,   364- 
374 
Tremors,    muscular,    during    anesthesia, 

381 
Tri-bromo-methane.      See    Bromoform 
Trichlorbutylidene   glycol.      See   Butyl- 
chloral  hydrate 
Trichlorethane,  831,  832 


INDEX 


943 


Trichlorethylen    dichlorid.      Sec    vEther 

auajstheticus   aranii 
Trichlorisopropylalcohol,    768 
Trichlormethane,        281.         See       also 

Chloroform 
Trichlorurum     formili.        See     Chloro- 
form 
Trimethylbenzoxypiperidinum        hydro- 

chloricum.      See   Eucain-B. 
Trimethylethylen,    698,    801,    802,    832. 

Sec  also  Amylene 
Trismus   during    anesthesia,    381 
Tropacocain,  540,  754,  832 

in    spinal    analgesia,    563,    571,    576, 
583,  599,  600,  601,  604 
Tropacocain    hydrochlorid,    832,    833 
Tropein,  832.     See  also  Tropacocain 
Tube  systems,  afferent  and  efferent,  in 
Sutton's    apparatus    for    colonic 
anesthesia,  449-451 
Tubes  for   ethyl   chlorid,   254-256 
glass   nasal,    for    general   anesthesia, 
227 
Tuberculosis,    choice    of    anesthetic    in, 
329 
use   of   guaiasanol   in,   762,    763 
Tucker,    use    of     magnesium    sulphate 

by,   771 
Tufl&er's   use  of   spinal   analgesia,  560, 

561,   569,  575,   598,  602,  604 
Tumor,     benign,     removal     of,     under 
local  anesthesia,  485 
circumscribed,    operation    for,    under 

local   anesthesia,   489 
in  airway,  chloroform  indicated  for, 

310 
in    the    antromaxillare,    case    of    re- 
moval of,   under  hypnotism,  646 
of    abdominal    wall,     operation    for, 

under  spinal  analgesia,  573 
of  neck,  operations  on,  under  colonic 

ether  anesthesia,  454 
removal   of,   by   blunt   dissection  un- 
der  local   anesthesia,   496 
under    the    sternum    in    status    lym- 
phaticus,   332 
Turpentine,   837,.  838 

oil  of,  as  preservative  of  chloroform, 
292 
Typhoid    fever,    sequestration    anesthe- 
sia    contra-indicated     following, 
470 

Udrenin,    838 

Ulceration,      ethyl     aminobenzoate     in 
cases  of,  737 

Ulcers   of    tongue,    sequestration    anes- 
thesia for  removal  of,   471 

Unipolar   methods   in  inducing   electric 
anesthesia,   631,   632,   636 

U.  S.  Army  statistics,   1904-1910,   842 
for  chloroform,    852 

U.  S.  Navy  statistics,   1908-1910,  842 
for  chloroform,   852 

United     States     Pharmocopo3ia,     ethyl 
chlorid   tests  prescribed  by,  257 


Universal  anesthotic,   839 
Upright  position  for  adenoid  and  ton- 
sil   operations,    345-352 
sequestration    anesthesia    with,    473- 
475 
Urea  and   quinin   hydrochlorid   in   local 

anesthesia,   483 
Urea  hydrochlorid,   540 

in    anesthetic    block    for    sliock    pre- 
vention, 406 
in  gastro-enterostomy,  356 
See    also    Quinin    and    urea    hydro- 
chlorid 
Urea-quinin   solution,   722 
Urethane,   838 

Urethra,  anesthetization  of,  by  alypin- 
gleitmittel,  696 
solution  for  local  anesthesia  of,   512 
Urethritis,  ethyl  aminobenzoate   in,  737 
Urethrotomy,      external,      under      local 
anesthesia,  485 
infiltration    in,    512 
Urinary     examination     in     intravenous 

anesthesia,  534 
Urine,  effect   of   anesthesia   on,   60,   61 
effect  of  chloroform  upon,   191,  303, 

304,   309 
effect   of   ether   upon,    190,   191,    197 
effect  of   nitrous  oxid   on,   132 
extravasation     of,     spinal     analgesia 

in,  587 
negative     findings     in,     after     ethyl 
chlorid  anesthesia,   264,   265 
Urobilinuria  following  anesthesia,  58 
Urosemin,   838 

Uterus,  effect  of  shock  on,   385 
operations  on,  shock  in,  403 

Vagina,  effect  of  shock  on,  386 

Valentine,  Basil,  858 

discovery  of  ethyl  chlorid  by,  250 

Valerene.     See  Amylene 

Valverdi,   4 

Valvular   disease,   nitrous   oxid   contra- 
indicated  in,  135 

Vanadium    steel    cylinders    for    nitrous 
oxid,  120 

Van  den  Berg  and  Sehoorl,  on  decom- 
position of  chloroform,   887 

Vanillin,   688 

Vanodrin,   839 

Vapor,     strength     of,     effect     of,     on 
breathing,  380 

Vapor  anesthesia  by  open  method,  231- 
235 

Vapor    generator    in    Sutton's    colonic 
anesthesia   apparatus,   444-449 

Vapor  inhaler,  first,   24 

Vapor   mask,   224,   232 

Varicose   ulcers   of   legs,    operation   on, 
under  spinal  analgesia,   625 

Varicose    vein    excision    under    intrave- 
nous anesthesia,   511 
under   spinal   analgesia,   573,   574 

Vascular  system,  effect  of  ethyl  chlorid 
on,  258,  260 


944 


INDEX 


Vasomotor  depression,  316 

Vasomotor  paralysis  as  cause  of  siiock, 

402-406 
Vein   exposed  and  ligated   distally  for 

intravenous   anesthesia,   526 
Venous,  anesthesia,    Bier 's   method   of, 

490-492 
Ventilation,  pulmonary,   after  ether  or 
chloroform,   107 
effect  of  morphin  on,  108 
Verliac's    apparatus    for   colonic    ether 

anesthesia,  442 
Verrier  on  effect  of  ether  on  lactation, 

192 
Vertigo    following   ethyl    chlorid    anes- 
thesia,  264 
Verworn  's  theory  of  anesthesia,  49,  50 
Veterinary  surgery,  chloral  hydrate  in, 

722 
Vienna  anesthetic,  689,   839 
Vienna     Elizabeth     Hospital     mixture. 

See  Wertheim's  mixture 
Vienna  General  Hospital  Mixture,  839, 

689 
Vienna  mixture,   703,  839 
Viferral.     See  Polychloral 
Vinci   on   eucain-B,    754 
Vinegar  fumes,  inhalation  of,  in  post- 
operative vomiting,  379 
"Vinegar  naphtha,"  736 
"Vinous  ether,"  178 
Vinyl    trichlorid,    750.      See    Ethylene 

chlorid 
Vinyldiacetonalkamin,    839 
Vitriolic   ether,   860 
Vitriol-naphtha,   860 
Vogt  on  spinal  analgesia,  565,  571 
Vogt's    method    of    inducing    hypnosis, 

658 
Voltaic   narcotism,   536 
Vomiting,   absence  of,  following  intra- 
tracheal insufflation,  430 
following  sequestration  anesthesia, 
471,  472 
after  anesthol  administration,  278 
after    colonic    ether    anesthesia,    438, 

453,   455,  458,  464 
after    ethyl   chlorid    anesthesia,    264, 

265 
after    use    of    ethyl    chlorid    and    ni- 
trous oxid,   279 
after  use   of  nitrous   oxid,    132 
during  anesthesia,   381 
during    chloroform    anesthesia,    306, 

307 
in  ether  anesthesia,   189 
in    ethyl-chlorid    oxygen    anesthesia, 

278 
in    peritonitis    or    intestinal    obstruc- 
tion,  355,   356 
in    spinal    analgesia,    577,    582,    583, 

595 
post-anesthetic,   102,  379 

effect  of  carbon  dioxid  on,  99 
effect  of  oil  of  bitter  orange  peel 
on,   94 


Vomiting,     post-anesthetic,     effect     of 
warming  the  agent  on,  70 
lessened   by   rebreathing,   113 
post-operative  dosage  for,  379 
prevention  of,   by  preliminary  medi- 
cation, 373 
with  Roth-Drager  oxygen  and  chloro- 
form  apparatus,   318 
Vreeland     oscillator,     electric     current 
produced  by,  635 

Wachsmuth  's   mixture,    839 
Wade  and  Finneniore,   on  alcohol  pre- 
pared from  ethyl  alcohol,  882 
Waite's  lokaler   Schmerztoter,  839 
Walsh,   James   J.,   on   mental  influence 

in   anesthesia,   644-653 
War   surgery,   ethyl   chlorid   anesthesia 

in,    266 
Ware      apparatus      for      administering 

ethyl  chlorid,  273 
Ware's  method  of  administering  ethyl 

chlorid,   272,   273 
Warmed  chloroform,  314,  315 
Warmed    ether    vapor    administration, 
by   closed  method,   244-245 
amount   of   anesthetic  for,   245 
care  of  apparatus  for,  245 
Warmed  ethyl  chlorid  vapor,  271 
Warming    anesthetic    agent,    63-76 
death   following,   67,   68 
effect    of,    on    after-effects    of    anes- 
thesia,  70 
on    body    temperature,    66-69 
on   convulsions,   65 
on  heart  action,  65 
on    recovery    from    anesthetic,    00 
on   reflexes,    65 
on   respiration,   65 
experiments    in,    with    ether    vapor, 

70-76 
safety  to  life  and,  63-66 
Warming  nitrous   oxid,   136 
Warren    and   ' '  sulphuric   ether, ' '   5 
Warrington  on  chloroform,  25 
Wart    removal    under   local   anesthesia, 

495 
Water   as   a   local   anesthetic,   839 
formation    of,    on    decomposition    of 

chloroform,    885,    887 
preparation  of  oxygen  from,  894 
presence  of,   in  chloroform,   889 

in  ether,  869,  870 
role  of,  in  anesthetic  ether,  867,  868 
Water    enema    during    anesthesia,    374, 
375,    376 
in   post-operative   treatment,    379 
warm,  in  oil-ether  colonic  anesthesia, 
460 
Water   infiltration   in   local   anesthesia, 

479,  489 
"Water   logging,"   prevention   of,   375 
Water   suction    apparatus    for   adenoid 

and  tonsil  operations,  343 
Water  vapor,  inspiration  of  compressed 
air  with,   77-80 


INDEX 


945 


Waugh  on  spinal  analgesia  for  chil- 
dren,  589 

Webster   on   ethyl   chlorid,   260 

Weidig,   779 

Weidig's  ansesthol,  710.  See  also 
Anasstliol. 

Wells,   Horace,   10,   11,   17,   24 

use  of  nitrous  oxid   iii   dentistry  by, 
118 

Welt   ana3sthetikum,   839 

Werner 's  method  of  purifying  chloro- 
form,  879 

Wertheim's    mixture,    839,    840 

Westron,  831.     See  Tetrachlorethane 

Wheal,  production  of,  in  skin  anes- 
thetization,   493-495 

Whiskey,    administration    of,    preceding 
anesthesia  in  alcoholics,  329 
in  post-operative  treatment,  378 
in    preliminary   medication,    371,   373 
with   saline   enema,   378 

White    on   residue    of    chloroform,    889 

' '  Wiggers '  anesthetic  ether, ' '  748. 
See  also  Ethyl  chlorid  poly- 
chlorated 

Wiki,   on   magnesium    sulphate,    771 

Willgerodt  's  discovery  of  acetone 
chloroform,   724 

Williams,  Probyn,  statistics  of,  on 
ether   and   on   chloroform,   854 

Williamson    on   methylated   ether,    861 

Williamson's  theory  of  etherification, 
863 


Willstatter,  tropacocain  prepared  by,  832 

Wilson 's    local    anesthetic,    840 

Winter  rose,   764 

Wireless     circuits,     electric     analgesia 
and  sleep   in,   631-633,   635,   6:;6 

Wood,     Alexander,     hypodermic     injec- 
tion for  dental  anesthesia  intro- 
duced   by,   536 
invention  of  hypodermic  syringe   hy, 
478 

Wood's  statistics  on  ethyl  chlorid,  848, 
849 

Woolsey.     See    Gwathmey-Woolsey 

Woolsey    method    of    employing    oil    of 
orange-ether   sequence,   94,   95 

Wright's  theory   of   anesthesia,  40,   41, 
42 

Wyeth  on  sequestration  anesthesia,  471 

Xanthates,   720 

Yankauer  mask  for  ether,  203,  232 
Yohimbin,    840 
Yohydrol,  840 

Yvon's    method    of    purifying    chloro- 
form,  880 

Ziemssen's     experiments     with     lumbar 

puncture,   557 
Zinc    chlorid    in    preparation    of    ethyl 

chlorid,    252 
presence   of,   in   ether,   864 
Zykloiorm,  840 


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